Venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thromboprophylaxis

Association of pathologic factors with postoperative venous thromboembolism after gastrointestinal cancer surgery

BACKGROUND

Venous thromboembolism (VTE) chemoprophylaxis is the standard of care after gastrointestinal (GI) cancer surgery; however, variation in risk based on pathologic factors (eg, stage and histology) is unclear. This study aimed to evaluate the association of pathologic factors with VTE after GI cancer surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program procedure targeted datasets were queried for patients who underwent colorectal, pancreatic, primary hepatic, and esophageal cancer surgery between 2017 and 2020. Disease-specific and pathologic factors associated with postoperative VTE were evaluated using multivariable logistic regression.

RESULTS

Among 70,934 patients who underwent GI cancer surgery, the incidence rates of 30-day postoperative VTE were 3.3% for pancreatic cancer, 3.2% for esophageal cancer, 2.7% for primary hepatic, and 1.3% for colorectal cancer. T stage was associated with VTE for colorectal cancer (T4 vs T1; odds ratio [OR], 1.79; 95% CI, 1.24-2.60), pancreatic cancer (all T stages vs T1; P < .05), and primary hepatic cancer (T4 vs T1; OR, 2.80; 95% CI, 1.55-5.08). N stage was associated with VTE for colorectal cancer (N2 vs N0; OR, 1.33; 95% CI, 1.04-1.68) and pancreatic cancer (N2 vs N0; OR, 1.36; 95% CI, 1.03-1.81). M stage was associated with VTE for colorectal cancer (OR, 1.47; 95% CI, 1.17-1.85) and esophageal cancer (OR, 2.54; 95% CI, 1.24-5.19). Histologic subtype was not associated with VTE, except for pancreatic neuroendocrine tumors vs adenocarcinoma (OR, 1.34; 95% CI, 1.03-1.74).

CONCLUSION

Pathologic factors were associated with higher 30-day VTE risk after GI cancer surgery. Acknowledging the association of pathologic factors on VTE is an important first step to considering a more tailored approach to chemoprophylaxis.

Patients with metastatic cancer have worse short-term coronary artery bypass grafting outcomes: A population-based study of National Inpatient Sample from 2015 to 2020

BACKGROUND

Metastasis is a hallmark for cancer progression. While patients with metastatic cancer (MC) have higher risk profiles, outcomes of coronary artery bypass grafting (CABG) in these patients have not been established, likely due to their smaller representation in the CABG patient population. This study aimed to examine the short-term outcomes of patients with MC who underwent CABG.

METHODS

Patients who underwent CABG were identified in National Inpatient Sample from Q4 2015-2020. Exclusion criteria included age <18 years, concomitant procedures, and non-metastatic malignancies. A 1:3 propensity-score matching was used to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status between MC and non-MCC patients. In-hospital post-CABG outcomes were evaluated.

RESULTS

There were 379 (0.23 %) patients with MC who underwent CABG. All MC patients were matched to 1161 out of 164,351 non-MC patients who underwent CABG during the same period. Patients with MC had higher risks of mortality (4.76 % vs 2.58 %, p = 0.04), pacemaker implantation (2.91 % vs 1.12 %, p = 0.03), venous thromboembolism (1.85 % vs 0.43 %, p = 0.01), and hemorrhage/hematoma (61.11 % vs 55.04 %, p = 0.04). In addition, MC patients had a longer time from admission to operation (3.35 ± 4.19 vs 2.82 ± 3.54 days, p = 0.03) and longer hospital length of stay (11.86 ± 8.17 vs 10.65 ± 8.08 days, p = 0.01).

CONCLUSION

Patients with MC had higher short-term mortality and morbidities after CABG. These findings can help provide insights for clinicians in the management of patients with concurrent coronary artery disease and MC, particularly in terms of preoperative risk stratification and therapeutic decision-making.

Evaluation of acute thrombus regression effect of edoxaban for deep vein thrombosis in patients with cancer: a single-center prospective observational study

BACKGROUND

Although there are reports on the recurrence prevention in the chronic phase using direct oral anticoagulants (DOACs) for deep vein thrombosis (DVT) in patients with cancer, acute thrombus regression effect using DOACs has not been assessed. This study aimed to assess the thrombus regression effect of initial treatment using edoxaban for acute lower-extremity DVT in patients with active cancer.

METHODS AND RESULTS

In this observational study, among the inpatients with cancer and lower-extremity DVT who underwent initial treatment with edoxaban at our hospital from November 2019 to December 2021, 34 consenting patients were recruited in this study. The quantitative ultrasound thrombus (QUT) score of thrombus volume was calculated at baseline (before administration) and 7-14 days after the start of edoxaban administration, using lower-extremity venous ultrasound to evaluate changes in thrombus volume. The primary and secondary endpoints were the acute thrombus regression effect of edoxaban and the impact of patients' clinical frailty on the thrombus regression effect, respectively. Anticoagulant therapy with edoxaban significantly reduced QUT score (p < 0.001). In addition, regardless of the Clinical Frailty Scale scores, QUT score decreased significantly.

CONCLUSION

Initial treatment with edoxaban was effective for lower-extremity DVT in patients with cancer. In addition, the effect was the same independent of the degree of frailty.

Seek and ye shall find: The utility of perioperative VTE screening in high-risk oncologic patients undergoing abdominopelvic surgery

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the prevalence and risk factors associated with perioperative venous thromboembolism (VTE) in patients undergoing major oncologic surgery using an epidural catheter (EC) for postoperative analgesia with mechanical prophylaxis and without chemoprophylaxis.

METHODS

Six hundred and twenty-six patients undergoing major oncologic surgery from 2009 to 2023 were evaluated. VTE was defined as deep vein thrombosis above the level of the knee. Lower extremity venous duplexes (LEVDs) were done preoperatively and postoperatively after the EC was removed. All patients received mechanical thromboprophylaxis, but not chemical prophylaxis, while the EC was in place. A generalized linear multivariable model was constructed to identify risk factors that predict pre and postoperative VTE.

RESULTS

29/626 patients (4.6%) were found to have preoperative VTE. 16/626 (2.6%) were found to have a postoperative VTE when their preoperative LEVD was negative. In comparison to patients without preoperative VTE, those with VTE were more likely to be male, anticoagulated, and have a history of coronary artery disease. Patients in the postoperative VTE group were older, male, anticoagulated, and had a history of VTE. On multivariable analysis, previous history of VTE was the risk factor most strongly associated with both pre and postoperative VTE.

CONCLUSION

Oncologic patients undergoing elective abdominopelvic surgery with epidural analgesia should be screened in the perioperative setting with LEVD to identify VTE and possibly prevent PE.

Clinical Features and Predictors of Mortality in Patients With Acute Pulmonary Embolism: A Retrospective Study From Southern Saudi Arabia

BACKGROUND AND METHODOLOGY

We aimed to investigate the clinical characteristics, outcomes, and mortality predictors in patients with acute pulmonary embolism (PE). Adult patients who were admitted to the Armed Forces Hospital Southern Region, Khamis Mushait, a large tertiary hospital in Southern Saudi Arabia, with the diagnosis of acute PE were retrospectively examined for the predictors of one-year mortality.

RESULTS

The overall in-hospital mortality was 15.6% among 212 patients. In univariate analysis, only age was significantly associated with increased early mortality, whereas age, obesity, presence of active malignancy, hypertension, use of thrombolytics, and Simplified Pulmonary Embolism Severity Index (sPESI) were significantly associated with increased late mortality. By use of binary logistic regression, the presence of obesity (HR 6.010, 95%CI 0.048-16.853, p=0.030), active malignancy (HR 3.040, 95%CI 1.147-8.059, p=0.025), and the use of thrombolytics (HR 8.074, 95%CI 2.719-23.977, p<0.001), were independently significant factors for late (overall) mortality, respectively.

CONCLUSIONS

Among Saudi Arabian patients in the Southern Region, our data show that age is an independent factor for increased early and late mortality. The presence of obesity, active malignancy, and the use of thrombolytics, were independently significant factors for increased late (one-year) mortality. These factors should be taken into account for risk stratification and decisions on tailored management of patients with PE. Further prospective multicenter studies are needed.

A Comprehensive Review of Risk Factors and Thrombophilia Evaluation in Venous Thromboembolism

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant cause of morbidity and mortality worldwide. There are many factors, both acquired and inherited, known to increase the risk of VTE. Most of these result in increased risk via several common mechanisms including circulatory stasis, endothelial damage, or increased hypercoagulability. Overall, a risk factor can be identified in the majority of patients with VTE; however, not all risk factors carry the same predictive value. It is important for clinicians to understand the potency of each individual risk factor when managing patients who have a VTE or are at risk of developing VTE. With this, many providers consider performing a thrombophilia evaluation to further define a patient's risk. However, guidance on who to test and when to test is controversial and not always clear. This comprehensive review attempts to address these aspects/concerns by providing an overview of the multifaceted risk factors associated with VTE as well as examining the role of performing a thrombophilia evaluation, including the indications and timing of performing such an evaluation.

A New Risk Prediction Model for Venous Thromboembolism and Death in Ambulatory Lung Cancer Patients

(1) Background: Venous thromboembolism (VTE) is a frequent complication in ambulatory lung cancer patients during chemotherapy and is associated with increased mortality. (2) Methods: We analyzed 568 newly diagnosed metastatic lung cancer patients prospectively enrolled in the HYPERCAN study. Blood samples collected before chemotherapy were tested for thrombin generation (TG) and a panel of hemostatic biomarkers. The Khorana risk score (KRS), new-Vienna CATS, PROTECHT, and CONKO risk assessment models (RAMs) were applied. (3) Results: Within 6 months, the cumulative incidences of VTE and mortality were 12% and 29%, respectively. Patients with VTE showed significantly increased levels of D-dimer, FVIII, prothrombin fragment 1 + 2, and TG. D-dimer and ECOG performance status were identified as independent risk factors for VTE and mortality by multivariable analysis and utilized to generate a risk score that provided a cumulative incidence of VTE of 6% vs. 25%, death of 19% vs. 55%, and in the low- vs. high-risk group, respectively (p < 0.001). While all published RAMs significantly stratified patients for risk of death, only the CATS and CONKO were able to stratify patients for VTE. (4) Conclusions: A new prediction model was generated to stratify lung cancer patients for VTE and mortality risk, where other published RAMs failed.

The Risk of Venous Thromboembolism in Korean Patients with Breast Cancer: A Single-Center Experience

The relationship between cancer and venous thromboembolism (VTE) has long been described. The risk of VTE in Asian patients with breast cancer remains largely unknown. This study described the incidence and risk factors of VTE in Korean patients with breast cancer. Data were collected from a retrospective database of patients who underwent breast cancer surgery between 2011 and 2020 at a single institution. The Cox proportional-hazards model was used to identify factors associated with VTE occurrences. Among the 2246 patients with breast cancer, 48 (2.1%) developed VTE during a median follow-up period of 53 months. The average incidence of VTE was 459 per 100,000 person-years. Age ≥ 60 years, male sex, chronic kidney disease, reconstructive procedures, and stage II or higher were independent predictive factors for VTE. VTE was associated with poor disease-free survival (hazard ratio (HR), 6.140; 95% confidence interval (CI), 3.480-10.835), and overall survival (HR, 8.842; 95% CI 4.386-17.824). Most VTE events were manageable with anticoagulation; three (6.3%) patients died of VTE, despite intensive care. The incidence of VTE was significantly elevated in Korean patients with breast cancer. Since VTE has a negative effect on oncologic outcomes of breast cancer, clinicians should manage its risk throughout their lifetime.

Efficacy and safety of novel oral anticoagulants for the treatment of cancer-associated venous thromboembolism: protocol for an umbrella review of systematic reviews and meta-analyses

INTRODUCTION

Novel oral anticoagulants (NOACs) have been used in antithrombotic therapy in patients with cancer, and their efficacy and safety have been evaluated in several meta-analyses. Although a large body of findings has accumulated to support the benefit of NOACs for the treatment and prevention of cancer-associated thromboembolism, there is no convincing evidence because of inconsistent results across studies and questionable data quality. Its efficacy and safety remain controversial, especially with regard to the risk of bleeding.

METHODS AND ANALYSIS

We will search PubMed, Embase and Web of science, Cochrane Library on 19 April 2022 (searches will be updated until complete) to identify systematic reviews, meta-analyses and pooled analyses of the efficacy and safety of NOACs for the treatment of cancer-associated venous thromboembolism. The quality of eligible systematic evaluations will be measured by A Measurement Tool to Assess Systematic Reviews. For each outcome, if a random effects model is not used, we will extract the data and estimate a 95% CI using the random effects model approach. For each random effects estimate, a 95% prediction interval is calculated. Heterogeneity between studies will be quantified using the I² metric. In addition, if an assessment contains at least three articles, we will reanalyse the assessment using Egger's asymmetry test to detect and visualise possible publication bias in the articles.

ETHICS AND DISSEMINATION

No formal ethical approval is required since we will use publicly available data. We will disseminate the findings of the umbrella review through publication in a peer-reviewed journal and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022342053.

Rivaroxaban bei tumorassoziierter venöser Thromboembolie

Diese Übersichtsarbeit beschreibt Erkenntnisse zur Prävention und Therapie der tumorassoziierten venösen Thromboembolie (VTE) mit direkten Faktor-Xa-Inhibitoren (FXaI) und bezieht sich insbesondere auf das Studienprogramm CALLISTO mit Rivaroxaban. CALLISTO umfasst randomisierte klinische Prüfungen unterschiedlicher Fragestellungen sowie Real-World-Evidenz.

Prävention und Therapie der tumorassoziierten VTE beruhten bisher auf niedermolekul1933aren Heparinen (NMH). Randomisierte kontrollierte Studien zeigten nun eine vergleichbare bis überlegene Wirksamkeit von FXaI vs. NMH. Die Erkenntnisse finden mittlerweile Eingang in Empfehlungen und Leitlinien. Zu beachten ist ein ggf. erhöhtes Blutungsrisiko, vor allem bei Patienten mit nicht resezierten gastrointestinalen oder urogenitalen Tumoren. Dieses wurde bei der Therapie mit FXaI zuerst beobachtet, kann jedoch auch NMH betreffen. Der Selektion geeigneter Patienten und der Optimierung von Behandlungspfaden kommt daher eine hohe Bedeutung zu.

Mitigating acute chemotherapy-associated adverse events in patients with cancer

Despite the enthusiasm surrounding novel targeted agents and immunotherapies, chemotherapy remains the mainstay treatment for most human malignancies, either alone or in combination. Yet, the burden of chemotherapy-associated adverse events (CAAEs) remains high and, importantly, is associated with considerable morbidity, mortality and costs that affect patients across multiple dimensions, including physical, emotional and social functioning. CAAEs can directly affect patient outcomes and indirectly increase the risk of cancer recurrence by compromising treatment intensity and continuity. Systematic efforts to identify and critically summarize the evidence on management approaches for CAAEs remain limited. Herein, we review the most common acute CAAEs having a major effect on survival, quality of life, function and/or continuation of optimal therapy. We focus on selected acute toxicities that occur during treatment, summarizing their underlying pathophysiology, multifactorial aetiologies, evidenced-based treatments, prevention strategies and management recommendations. We also summarize the available evidence on risk factors, validated risk assessment tools and other efforts to optimize symptom control in patients most likely to benefit in order to personalize the prevention and treatment of acute CAAEs. Finally, we discuss innovative symptom monitoring and supportive care interventions that are under development to further improve the outcomes of patients with cancer.

A review of the current ERAS guidelines for liver resection, liver transplantation and pancreatoduodenectomy

In perioperative care after liver resection, transplantation and pancreatoduodenectomy, ERAS (Enhanced Recovery After Surgery) recommendations are based on the reducing invasiveness of procedures and the severity of the surgical stress, which results in decreasing complications and enhanced recovery. Recommendations for all three operations can be classified into five groups: recommended for all patients, recommended for special patient groups, rejected for all patients, controversial recommendations, specific recommendations for all three operations. Preoperative counselling and psychological support, nutritional support, smoking and alcohol cessation, pre- and intraoperative antibiotic prophylaxis, thrombosis prevention, limiting of preoperative hunger and thirst to 4 and 6 h, preoperative intaking carbohydrate rich drink, alcohol-based antiseptics for skin preparation, a goal-directed infusion therapy, providing normothermia, early removal of the drainage tube, glycemic control, dual antiemetic therapy, multimodal analgesia strategies, early oral feeding and activation, audit recommend for all patients. Postoperative antibiotic prophylaxis, enteral and parenteral nutrition, short-acting anxiolytics are recommended for individual patients. It is recommended to avoid Mercedes type incision, use of long-acting anxiolytics and postoperative nasogastric tube. The benefits of preoperative physical exercise, immunonutrition and probiotics are controversial. There are no specific recommendations for thoracic epidural anesthesia, preventing delayed gastric emptying and intestinal paresis in liver surgery.

Aspirin and cancer: biological mechanisms and clinical outcomes

Evidence on aspirin and cancer comes from two main sources: (1) the effect of aspirin upon biological mechanisms in cancer, and (2) clinical studies of patients with cancer, some of whom take aspirin. A series of systematic literature searches identified published reports relevant to these two sources. The effects of aspirin upon biological mechanisms involved in cancer initiation and growth appear to generate reasonable expectations of effects upon the progress and mortality of cancer. Clinical evidence on aspirin appears overall to be favourable to the use of aspirin, but evidence from randomized trials is limited, and inconsistent. The main body of evidence comes from meta-analyses of observational studies of patients with a wide range of cancers, about 25% of whom were taking aspirin. Heterogeneity is large but, overall, aspirin is associated with increases in survival and reductions in metastatic spread and vascular complications of different cancers. It is important that evaluations of aspirin used as an adjunct cancer treatment are based upon all the available relevant evidence, and there appears to be a marked harmony between the effects of aspirin upon biological mechanisms and upon the clinical progress of cancer.

Cancer Histology and Natural History of Patients with Lung Cancer and Venous Thromboembolism

Simple Summary

Cancer is a widely heterogeneous disease, and the natural history of patients with cancer-associated thrombosis may differ according to the cancer site. Lung cancer is the most common malignancy, and a leading cause of death. A number of studies in the literature suggest that patients with adenocarcinoma may have a worse outcome than those with squamous or other types of lung cancer. The aim of the current study was to assess the potential impact of lung cancer histology on the incidence rates of VTE recurrences, major bleeding, or death appearing during the course of anticoagulation, in patients with lung cancer and VTE. Our findings, obtained from a large series of consecutive patients with lung cancer and VTE (482 patients), reveal important differences between patients with adenocarcinoma vs. other histologies in their outcomes during anticoagulation. This might likely help to design better therapeutic strategies for patients with lung cancer.

Abstract

Background: In patients with lung cancer and venous thromboembolism (VTE), the influence of cancer histology on outcome has not been consistently evaluated. Methods: We used the RIETE registry (Registro Informatizado Enfermedad TromboEmbólica) to compare the clinical characteristics and outcomes during anticoagulation in patients with lung cancer and VTE, according to the histology of lung cancer. Results: As of April 2022, there were 482 patients with lung cancer and VTE: adenocarcinoma 293 (61%), squamous 98 (20%), small-cell 44 (9.1%), other 47 (9.8%). The index VTE was diagnosed later in patients with squamous cancer than in those with adenocarcinoma (median, 5 vs. 2 months). In 50% of patients with adenocarcinoma, the VTE appeared within the first 90 days since cancer diagnosis. During anticoagulation (median 106 days, IQR: 45–214), 14 patients developed VTE recurrences, 15 suffered major bleeding, and 218 died: fatal pulmonary embolism 10, fatal bleeding 2. The rate of VTE recurrences was higher than the rate of major bleeding in patients with adenocarcinoma (11 vs. 6 events), and lower in those with other cancer types (3 vs. 9 events). On multivariable analysis, patients with adenocarcinoma had a non-significantly higher risk for VTE recurrences (hazard ratio [HR]: 3.79; 95%CI: 0.76–18.8), a lower risk of major bleeding (HR: 0.29; 95%CI: 0.09–0.95), and a similar risk of mortality (HR: 1.02; 95%CI: 0.76–1.36) than patients with other types of lung cancer. Conclusions: In patients with lung adenocarcinoma, the rate of VTE recurrences outweighed the rate of major bleeding. In patients with other lung cancers, it was the opposite.

New Oral Anticoagulants Open New Horizons for Cancer Patients with Venous Thromboembolism

Venous thromboembolism (VTE) is associated with increased morbidity and mortality, decreased quality of life, and higher economic burden in patients with cancer. Currently, the treatment of VTE in patients with cancer is particularly challenging. For many years, low molecular weight heparin (LMWHs) has been the standard for the treatment of cancer-associated VTE. Recently, the introduction of new oral anticoagulants (NOACs) may offer an oral anticoagulant option for some patients with cancer-associated thrombosis (CAT) as a growing body of literature supports the use of NOACs in the setting of CAT. With the use of NOAC as a new option in the management of CAT, clinicians now face several choices for the individual cancer patient with VTE. We need a more in-depth understanding of the drug properties, efficacy and safety, economic analysis that allows us to choose the most appropriate treatment for each patient. In the review, we will present an overview of CAT management, discuss the available evidence, economic costs for NOACs in the treatment of CAT, and seek to provide the best range of treatments for cancer patients.

Prevalence of Hemorrhagic Complications in Hospitalized Patients with Pulmonary Embolism

Background: The prevalence of anticoagulant therapy-associated hemorrhagic complications in hospitalized patients with pulmonary embolism (PE) has been scarcely investigated. Aim: To evaluate the prevalence of hemorrhages in hospitalized PE patients. Methods: The Information System “ASKLIPIOS™ HOSPITAL” implemented in the Respiratory Medicine Department, University of Thessaly, was used to collect demographic, clinical and outcome data from January 2013 to April 2021. Results: 326 patients were included. Males outnumbered females. The population’s mean age was 68.7 ± 17.0 years. The majority received low molecular weight heparin (LMWH). Only 5% received direct oral anticoagulants. 15% of the population were complicated with hemorrhage, of whom 18.4% experienced a major event. Major hemorrhages were fewer than minor (29.8% vs. 70.2%, p = 0.001). Nadroparin related to 83.3% of the major events. Hematuria was the most common hemorrhagic event. 22% of patients with major events received a transfusion, and 11% were admitted to intensive care unit (ICU). The events lasted for 3 ± 2 days. No death was recorded. Conclusions: 1/5 of the patients hospitalized for PE complicated with hemorrhage without a fatal outcome. The hemorrhages were mainly minor and lasted for 3 ± 2 days. Among LMWHs, nadroparin was related to a higher percentage of hemorrhages.

Rivaroxaban versus placebo for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer

Rivaroxaban is superior to placebo for extended prevention of venous thromboembolism after laparoscopic surgery for colorectal cancer.

Rivaroxaban did not increase bleeding during extended prevention of venous thromboembolism after laparoscopic surgery for colorectal cancer.

The clinical benefit of extended prophylaxis for venous thromboembolism (VTE) after laparoscopic surgery for cancer is unclear. The efficacy and safety of direct oral anticoagulants for this indication are unexplored. PROphylaxis of venous thromboembolism after LAParoscopic Surgery for colorectal cancer Study II (PROLAPS II) was a randomized, double-blind, placebo-controlled, investigator-initiated, superiority study aimed at assessing the efficacy and safety of extended prophylaxis with rivaroxaban after laparoscopic surgery for colorectal cancer. Consecutive patients who had laparoscopic surgery for colorectal cancer were randomized to receive rivaroxaban (10 mg once daily) or a placebo to be started at 7 ± 2 days after surgery and given for the subsequent 3 weeks. All patients received antithrombotic prophylaxis with low-molecular-weight heparin from surgery to randomization. The primary study outcome was the composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected deep vein thrombosis (DVT), or VTE-related death at 28 ± 2 days after surgery. The primary safety outcome was major bleeding. Patient recruitment was prematurely closed due to study drug expiry after the inclusion of 582 of the 646 planned patients. A primary study outcome event occurred in 11 of 282 patients in the placebo group compared with 3 of 287 in the rivaroxaban group (3.9 vs 1.0%; odds ratio, 0.26; 95% confidence interval [CI], 0.07-0.94; log-rank P = .032). Major bleeding occurred in none of the patients in the placebo group and 2 patients in the rivaroxaban group (incidence rate 0.7%; 95% CI, 0-1.0). Oral rivaroxaban was more effective than placebo for extended prevention of VTE after laparoscopic surgery for colorectal cancer without an increase in major bleeding. This trial was registered at www.clinicaltrials.gov as #NCT03055026.

Venous thromboembolism in Cancer surgery: A report from the Nationwide readmissions database

Background

The present study characterized the incidence of venous thromboembolism in a contemporary cohort of surgical oncology patients and its association with index hospitalization and postdischarge outcomes.

Methods

Adults undergoing 7 major thoracic and abdominal cancer resections were identified in the 2016–2019 Nationwide Readmissions Database. Multivariable models stratified by operative subtype were developed to evaluate the association of venous thromboembolism with outcomes of interest.

Results

Of an estimated 436,368 patients, venous thromboembolism was identified in 9,811 (2.2%) patients during index hospitalization. Esophageal (4.1%) and gastric (4.1%) resections exhibited the highest rates of venous thromboembolism, whereas pulmonary resection (1.0%) the lowest. Following adjustment, cancer resection type demonstrated the strongest association with venous thromboembolism development among all factors analyzed (adjusted odds ratio: 3.13, 95% confidence interval: 2.60–3.78). Diagnosis of venous thromboembolism was associated with increased mortality (10.2%, 95% confidence interval: 9.4–11.1 vs 1.7, 95% confidence interval: 1.6–1.7) and prolonged index hospital stay (19.5 days, 95% confidence interval: 19.1–20.0 vs 7.5, 95% confidence interval: 7.4–7.5). Of patients who survived index hospitalization, venous thromboembolism occurrence was associated with increased risk of nonhome discharge (56.4%, 95% confidence interval: 54.7–58.0 vs 14.4, 95% confidence interval: 14.2–14.7) and readmission (30.0%, 95% confidence interval: 28.5–31.1 vs 16.9, 95% confidence interval: 16.7–17.1). Additionally, venous thromboembolism substantially increased index hospitalization ($40,000, 95% confidence interval: $38,000–$42,000) and readmission costs ($3,200, 95% confidence interval: $1,700–$4,700).

Conclusion

Rates of venous thromboembolism remain high in surgical oncology patients, with cancer resection type as a major predictor of venous thromboembolism incidence. Venous thromboembolism was associated with inferior clinical and financial outcomes that extended beyond discharge. These findings underscore the importance of continued vigilance and procedure-specific prophylaxis measures.

Management of cancer-associated thrombosis with thrombocytopenia: Impact of the ISTH guidance statement

Background

Optimal management of cancer-associated thrombosis (CAT) in patients with thrombocytopenia remains difficult given competing risks of recurrent thrombosis and increased bleeding. We determine the impact of the ISTH Scientific and Standardization Committee (SCC) guidance on CAT management and thrombocytopenia on platelet transfusion, bleeding, and recurrent thrombosis.

Methods

A retrospective review was performed of patients with CAT and thrombocytopenia who required anticoagulation for VTE for 11 months before and after implementation of the ISTH SCC guidance. Medical records were reviewed to identify the type of VTE event, number of platelet transfusions, incidence of bleeding, and VTE recurrence within pre- and postintervention time periods.

Results

A total of 41 and 80 cases were included in the preintervention and postintervention periods, respectively. The preintervention group showed a trend toward less acute VTE events (39% vs 55%; P = .05). The postintervention period had an increased per-patient platelet transfusion (median, 2.5 vs 4; P = .05). Nonmajor bleeding was increased in the postintervention group (2% vs 16%; P = 0.03) and included all six (8%) major hemorrhages (P = .09). There was numerically less recurrent thrombosis in the postintervention group (20% vs 8%; P = .07), which was not significantly different when accounting for acuity of VTE. Management adherence was strong, at 91%, in the postintervention group.

Conclusion

The ISTH guidance on management of cancer-associated thrombosis in patients with thrombocytopenia was successfully implemented in an academic medical center. There was no significant difference in bleeding or recurrent thrombosis outcomes after adjusting for acuity of VTE.

Potential Role of Neutrophil Extracellular Traps in Cardio-Oncology

Cardiovascular toxicity has emerged as the leading cause of death in patients undergoing cancer treatment. Thus, cardio-oncology (CO) care must also focus on the prevention and management of related cardiovascular (CV) complications caused by cancer therapy. Neutrophil extracellular traps (NETs)—entities with released DNA, proteases, proinflammatory and prooxidative substances from blasted neutrophils—play an important role in cancer proliferation, propagation metastasis, and incident CV events (acute coronary syndrome, thromboembolic events, and heart failure). Although NETs have been shown to be involved in cancer progression and incident CV events, little is known about their relationship with cardio-oncology, especially on cancer treatment-related cardiovascular toxicity (CTRCT). This review aims to explore the evidence of the impact of NETs on cancer, CV events, and CTRCT, and the possible solutions based on the mechanism of NETs activation and NETs released toxic substances.

Prediction models for venous thromboembolism in ambulatory adults with pancreatic and gastro-oesophageal cancer: protocol for systematic review and meta-analysis

INTRODUCTION

Venous thromboembolism (VTE) is a common complication of cancer. Pancreatic and gastro-oesophageal cancers are among malignancies that have the highest rates of VTE occurrence. VTE can increase cancer-related morbidity and mortality and disrupt cancer treatment. The risk of VTE can be managed with measures such as using anticoagulant drugs, although the risk of bleeding may be an impeding factor. Therefore, a VTE risk assessment should be performed before the start of anticoagulation in individual patients. Several prediction models have been published, but most of them have low sensitivity and unknown clinical applicability in pancreatic or gastro-oesphageal cancers. We intend to do this systematic review to identify all applicable published predictive models and compare their performance in those types of cancer.

METHODS AND ANALYSIS

All studies in which a prediction model for VTE have been developed, validated or compared using adult ambulatory patients with pancreatic or gastro-oesphageal cancers will be identified and the reported predictive performance indicators will be extracted. Full text peer-reviewed journal articles of observational or experimental studies published in English will be included. Five databases (Medline, EMBASE, Web of Science, CINAHL and Cochrane) will be searched. Two reviewers will independently undertake each of the phases of screening, data extraction and risk of bias assessment. The quality of the selected studies will be assessed using Prediction model Risk Of Bias Assessment Tool. The results from the review will be used for a narrative information synthesis, and if the same models have been validated in multiple studies, meta-analyses will be done to pool the predictive performance measures.

ETHICS AND DISSEMINATION

There is no need for ethics approval because the review will use previously peer-reviewed articles. The results will be published.

PROSPERO REGISTRATION NUMBER

CRD42021253887.

Effectiveness and Safety of Direct Oral Anticoagulants vs. Warfarin and Recurrence After Discontinuation in Patients With Acute Venous Thromboembolism in the Real World

BACKGROUND

The efficacy of direct oral anticoagulants (DOACs) compared with warfarin for the treatment of venous thromboembolism (VTE), and the recurrence of VTE after discontinuation of anticoagulation therapy in research are limited.Methods and Results:This retrospective study enrolled 893 patients with acute VTE between 2011 and 2019. The cohort was divided into the transient risk, unprovoked, continued cancer treatment, and cancer remission groups. The following were compared between DOACs and warfarin: composite outcome of all-cause death, VTE recurrence, bleeding and composite outcome of VTE-related death, recurrence and bleeding. In the continued cancer treatment group, more bleeding was seen in warfarin-treated patients than in patients treated with DOACs (53.2% vs. 31.2%, [P=0.048]). In addition, composite outcome of VTE-related death and recurrence after discontinuation of anticoagulation therapy (n=369) was evaluated. The continued cancer treatment group (multivariate analysis: HR: 3.62, 95% CI: 1.84-7.12, P<0.005) and bleeding-related discontinuation of therapy (HR: 2.60, 95% CI: 1.32-5.13, P=0.006) were independent predictors of the event after discontinuation of anticoagulation therapy. VTE recurrence after discontinuation of anticoagulation therapy in the cancer remission group was 1.6% and a statistically similar occurrence was found in the transient risk group (12.4%) (P=0.754).

CONCLUSIONS

DOACs may decrease bleeding incidence in patients continuing to receive cancer treatment. In patients with bleeding-related discontinuation of anticoagulation therapy, VTE recurrence may increase. Discontinuation of anticoagulant therapy might be a treatment option in patients who have completed their cancer treatment.

An Overview of Cardio-Oncology, a New Frontier to Be Explored

Advances in cancer treatments have led to an increasing number of cancer survivors, but also high rates of short- and long-term cardiovascular (CV) toxicities. The number of new cancer drugs is constantly increasing, and the uncertain CV toxicities of these drugs make long-term care and monitoring difficult. Moreover, traditional type I and type II cardiotoxicities may not be applicable to all of these agents. Multidisciplinary care with expertise in oncology, cardiology and other related specialties is required to mitigate cancer therapeutics-related cardiovascular dysfunction (CTRCD). The aim of this review is to provide an overview of the main CTRCD, risk assessment, early diagnosis, and strategies for the prevention and management of patients receiving cancer therapies. There are still unmet needs for cardio- oncology researchers with regards to early detection measures, better treatment strategies, better follow-up protocols, and better management of CTRCD. Experts in cardiology, oncology, hematology, and radio-oncology should thus work closely in an attempt to foster patient awareness and research in this field, as well as call for support from public and industrial sources to initiate pivotal clinical trials to solve these unmet needs.

The Role of Direct Oral Anticoagulants in Cancer-Associated Thrombosis According to the Current Literature

Venous thromboembolism (VTE) is a common complication among patients suffering from malignancies, leading to an increased mortality rate. Novel randomized trials have added valuable information regarding cancer-associated thrombosis (CAT) management using direct oral anticoagulants (DOACs). The aim of this study is to present an overview of the current literature and recommendations in CAT treatment. A few randomized control trials (RCTs) have been integrated suggesting that DOACs may be effectively applied in CAT patients compared to low molecular weight heparins (LMWHs) with a decreased mortality and VTE recurrence rate. However, the risk of bleeding is higher, especially in patients with gastrointestinal malignancies. Real-world data are in accordance with these RCT findings, while in the currently available recommendations, DOACs are suggested as a reliable alternative to LMWH during the initial, long-term, and extended phase of treatment. Data retrieved from the current literature, including RCTs and “real-world” studies, aim to clarify the role of DOACs in CAT management, by highlighting their benefits and remarking upon the potential adverse outcomes. Current recommendations suggest the use of DOACs in well-selected patients with an increasing level of evidence through years.

A comprehensive review of DOACs for cancer associated VTE prophylaxis or treatment

Cancer is a leading cause of venous thromboembolism (VTE), which contributes to significant morbidity and mortality in these patients. Increased thrombotic risk in cancer patients is modified by tumor-specific biology, disease-directed interventions, and individual comorbidities. Risk stratification for prophylaxis and treatment requires regular reevaluation of these factors, which can be facilitated by validated prediction tools. This review also discusses large clinical trial data (SELECT-D, HOKUSAI-VTE, ADAM VTE, CARAVAGGIO) demonstrating that direct oral anticoagulants (DOACs) are effective in the treatment of cancer-associated VTE, with comparable efficacy to the traditional choice of low molecular weight heparin. In the prophylactic setting derived from patients with cancer with increased VTE risk, DOACs also reduced the incidence of VTE with only modest increases in bleeding risk. The ease of DOAC administration and acceptable risk profile in the carefully selected patient make them an appealing choice for anticoagulation. In instances where the risk of gastrointestinal bleeding is of concern, apixaban, in particular, may still be a suitable option in place of LMWH. These improvements in our anticoagulation approach to cancer-associated VTE are well-timed to accompany the recent advances in disease-directed therapies that are enabling patients to live longer with cancer and therefore at increased risk of complications such as VTE.

[Predicting the Incidence of Venous Thromboembolism Using the Khorana Score: A Literature Review]

Venous thromboembolism (VTE) is the second most common cause of cancer-related deaths globally. The Khorana score, a VTE prediction model, is calculated using the site of cancer, white blood cell count, hemoglobin level, platelet count, and body mass index. This study aimed to investigate the usefulness of the Khorana score, using data available in the literature. On July 28, 2020, we collected papers using the following keywords: "cancer", "venous thromboembolism", "deep vein thrombosis", "pulmonary embolism", and "Khorana score" on PubMed. Papers published after 2016 were eligible. The selection criteria were as follows: "English or Japanese", "original paper", "abstract and full text", and "comply with the clinical question". There were 131 papers that matched the keywords, and 15 of them complied with the selection criteria. In 15 papers, Khorana score was calculated in 8047 patients. In the low- and intermediate-risk groups, 532 of 6812 patients developed VTE [7.8%, 95%confidence intervals (CI) 7.2-8.5], whereas in the high-risk group, 127 of 1235 patients developed VTE (10.3%, 95% CI 8.7-12.1) [odds ratio (OR) 1.3, 95% CI 1.0-1.6] (I²=0%, τ²=0, p=0.50). Venous thromboembolism prediction using the Khorana score might be useful. However, most of the number of VTE patients are in the low- and intermediate-risk groups. Therefore, a comprehensive evaluation according to clinical conditions is required, regardless of the risk classification using the Khorana score.

Anticoagulant Therapy for Cancer-Associated Venous Thromboembolism after Cancer Remission

Objectives: To examine the outcomes of anticoagulant therapy for patients with venous thromboembolism (VTE) with active cancer and the outcomes after cancer remission with and without anticoagulant therapy. Materials and Methods: Of the 338 patients with cancer-associated VTE who received anticoagulant therapy, we evaluated therapeutic outcomes over 1 year for 112 patients whose cancers were in remission (cancer remission group) and 226 patients who continued cancer treatment (continued cancer treatment group). Further, the cancer remission group was divided into 89 and 23 patients who completed (completion of anticoagulation group) and continued (continued anticoagulation group) anticoagulant therapy, respectively. Treatment outcomes after completing anticoagulant therapy were compared between these two groups. The follow-up period was 1 year, and the endpoints were all-cause death, VTE recurrence, and bleeding events. Results: The event-free survival rates were 99.1% and 42.9% in the cancer remission and continued cancer treatment groups, respectively. For treatment outcomes after the completion of anticoagulant therapy, the event-free survival rates were 98.9% and 87% in the completion of anticoagulation and continued anticoagulation groups, respectively (log rank, P=0.005). Conclusion: When cancer is in remission, recurrence is low even if anticoagulant therapy is terminated after a certain period.

Clinical practice guidelines for the treatment and prevention of cancer-associated thrombosis

The risk of venous thromboembolism (VTE) is increased in patients with cancer and is greatest in those with cancers of the pancreas, stomach, brain, lung and ovary, late stage disease and in those undergoing treatment including chemotherapy, hormonal therapy, or surgery. VTE in patients with cancer is associated with a variety of adverse consequences including an increased risk of VTE recurrence, major bleeding, and early mortality. A VTE risk score for ambulatory patients receiving cancer chemotherapy has been extensively validated and has been used to select high risk patients for thromboprophylaxis trials. Several randomized controlled trials (RCTs) and meta-analyses of these trials have confirmed that LMWHs can significantly reduce the risk of VTE in patients with cancer. While the direct oral anticoagulants (DOACs) have been approved for the general population, previous guideline panels discouraged their use due to a lack of cancer-specific data. Recently RCTs for the treatment of established VTE in patients with cancer have demonstrated that the risk of recurrent VTE is lower while the risk of bleeding greater with DOACs compared to LMWH. Two thromboprophylaxis trials comparing low dose DOACs to placebo in high risk patients receiving cancer therapy have recently reported similar rates of VTE occurrence at 6 months in the control arms. A meta-analysis of the pooled results from these trials in higher risk ambulatory patients receiving cancer therapy confirmed a significant reduction in overall VTE incidence as well as pre-planned secondary outcomes on treatment. Several clinical practice guidelines addressing VTE in patients with malignant disease have been updated including those from the American Society of Clinical Oncology (ASCO). The addition of DOACs as an option for the management of VTE in patients with cancer is the latest major change to previous guidelines issued by these organizations. The updated recommendations from these guidelines are summarized in this review.

Cancer and Thrombosis: New Treatments, New Challenges

The direct-acting oral anticoagulant (DOAC) has become an alternative to low-molecular-weight heparin (LMWH) for treatment and prophylaxis of venous thromboembolism (VTE) in cancer patients. The clinicians are, however, faced with difficult decisions regarding DOAC treatment: Which patients cannot use DOACs? Should incidental VTE be treated similar to symptomatic VTE? Is it safe to give DOACs to patients with gastrointestinal or urogenital cancers? How about drug–drug interactions? Should all cancer patients receive thromboprophylaxis? Is arterial thrombosis a problem? The current article reviews the available literature regarding these questions and aims to provide practical solutions based on data from the clinical trials and new guidelines.

Epidemiology of Cancer-Associated Thrombosis in Asia: A Systematic Review

The epidemiology of cancer associated thrombosis (CAT) in Asia is less well-studied and differs from that in the western countries. Here, we systematically examine population based and hospital-based studies reported between 1995 and 2020 to understand the epidemiology of CAT in Asia. From population-based studies, the estimated incidence of VTE in cancer patients was 1.85–9.88 per 1,000 person-years. The incidence of CAT in Asia is significantly higher than non-cancer associated VTE in the general population and cancer is perhaps the most important risk factor for VTE. Hospital-based studies were heterogeneous in study designs and reveal a wide range of prevalence of VTE among cancer patients at 0.5–44.6% while the cancer prevalence rates among VTE patients ranged from 6.1 to 65.5%. The cancer sites most associated with VTE and risk factors were similar between Asian and Western studies. CAT has a major impact on the survival of patients with cancer in Asia, but thromboprophylaxis is not commonly practiced and validated risk assessment tools are lacking. This study highlights the urgent need for large multinational epidemiological studies in Asia to establish the true burden of CAT and to guide appropriate prevention strategies.

Risk Factors for Gastric Cancer-Associated Thrombotic Diseases in a Han Chinese Population

The aim of the present work was to investigate the risk factors for gastric cancer- (GC-) associated thrombotic diseases in a Han Chinese population. A total of 333 patients diagnosed with GC, 68 with thrombotic diseases included in the case group and the remaining 265 in the control group, were enrolled. The relevant data for the participants, including general information (gender, age, smoking, and drinking), comorbidities (diabetes, hypertension, and anemia), tumor-related data (tumor site, histology, degree of differentiation, and clinical stage), and treatment-related data (surgery, chemotherapy, hormones, transfusion, and peripherally inserted central venous catheter (PICC)), were collected. Statistically significant factors derived from univariate analyses were then subjected to multivariate logistic regression analyses. The results demonstrate a statistically significant difference in age, diabetes, hypertension, histology, surgery, chemotherapy, and PICC (P < 0.05), compared with control. Age, diabetes, surgery, and PICC serve as independent risk factors for GC-associated thrombotic diseases (P < 0.05). The present work demonstrates that GC-associated thrombotic diseases are significantly associated with age, diabetes, surgery, and PICC, suggesting a potential target for early detection and preventive strategy for GC patients with thrombophilia.

Development and validation of a risk calculator for post-discharge venous thromboembolism following hepatectomy for malignancy

BACKGROUND

Post-discharge venous thromboembolism (VTE) chemoprophylaxis decreases VTEs following cancer surgery, however identifying high-risk patients remains difficult. Our objectives were to (1) identify factors available at hospital discharge associated with post-discharge VTE following hepatectomy for malignancy and (2) develop and validate a post-discharge VTE risk calculator to evaluate patient-specific risk.

METHODS

Patients who underwent hepatectomy for malignancy from 2014 to 2017 were identified from the ACS NSQIP hepatectomy procedure targeted module. Multivariable logistic regression identified factors associated with post-discharge VTE. A post-discharge VTE risk calculator was constructed, and predicted probabilities of post-discharge VTE were calculated.

RESULTS

Among 11 172 patients, 95 (0.9%) developed post-discharge VTE. Post-discharge VTE was associated with obese BMI (OR 2.29 vs. normal BMI [95%CI 1.31-3.99]), right hepatectomy/trisegmentectomy (OR 1.63 vs. partial/wedge [95%CI 1.04-2.57]), and several inpatient postoperative complications: renal insufficiency (OR 5.29 [95%CI 1.99-14.07]), transfusion (OR 1.77 [95%CI 1.12-2.80]), non-operative procedural intervention (OR 2.97 [95%CI 1.81-4.86]), and post-hepatectomy liver failure (OR 2.22 [95%CI 1.21-4.08]). Post-discharge VTE risk ranged from 0.3% to 30.2%. Twenty iterations of 10-fold cross validation identified internal validity.

CONCLUSIONS

Risk factors from all phases of care, including inpatient complications, are associated with post-discharge VTE following hepatectomy. Identifying high-risk patients may allow for personalized risk-based post-discharge chemoprophylaxis prescribing.

The Comparison Between Non-High Risk Patients with and Without Cancer Diagnosed with Pulmonary Embolism

Objective

This study aimed to compare the pulmonary embolism (PE) location and clot burden on computed tomography pulmonary angiography (CTPA), the degree of right ventricular dysfunction (RVD), D-dimer, and cardiac troponin I (cTnI) levels, and the presence of a lower extremity deep venous thrombosis (DVT) in patients with and without cancer diagnosed with a non high risk pulmonary embolism (PE).

Method

We calculated Miller score for each patient for clot burden. The location of PE was also evaluated at CTPA. D-dimer and cardiac cTnI levels were measured. Patients had echocardiography for RVD and lower extremity color flow Doppler ultrasonography for DVT.

Results

The study included 71 patients with PE. The patients were divided into two groups according to the presence of cancer. There was no statistically significant difference for D-dimer levels (P=0.15), PE location (p=0.67), clot burden (P=0.34), RVD (P=0.28) and DVT (P=0.33) between groups (P=0.15). Cancer patients diagnosed as PE had statistically significantly higher levels of cTnI than those who were diagnosed as PE without cancer (P=0.03).

Conclusion

There was no significant difference between patients diagnosed as PE with and without cancer in terms of D-dimer levels, clot burden and emboli location, RVD and DVT. cTnI levels were higher in non-high risk PE patients with cancer than these patients without cancer.

Posthospital discharge venous thromboembolism prophylaxis among colorectal and hepatobiliary surgeons: A practice survey

BACKGROUND

Recent practice guidelines recommend venous thromboembolism prophylaxis for 28 days after cancer surgery. We sought to characterize and compare awareness, agreement, adoption, and adherence to these guidelines among surgeons.

METHODS

We electronically surveyed Canadian hepatobiliary surgeons registered with the Canadian Hepatopancreatobiliary Association, general and colorectal surgeons registered with the College of Physicians and Surgeons of Ontario and the Canadian Society of Colorectal Surgeons who provide colorectal cancer care with a pilot-tested questionnaire. Attitudes to relevant guideline recommendations and perceived barriers to postdischarge venous thromboembolism prophylaxis were assessed on a 5-point Likert scale.

RESULTS

There were 128 responses (response rate 60%, 128 of 213), including 60 general/colorectal and 68 hepatobiliary surgeons. Most surgeons were aware (122 of 128, 95%), agreed (101 of 122, 83%), adopted (78 of 101, 77%), and adhered (74 of 78, 95%) with guidelines. Preexisting venous thromboembolism-prophylaxis hospital programs, hepatobiliary surgeons, and geographical region were associated with increased likelihood of adherence. Among respondents that did not agree, insufficient evidence (median Likert: 4, interquartile range 3-5) and low incidence of venous thromboembolism (median Likert: 4, interquartile range 3-4) were cited as the strongest barriers. Surgeons who agreed but did not adopt these programs reported that the most significant barriers were "drug cost" (median Likert: 4, interquartile range 3-4) and "subcutaneous injections" (median Likert: 4, interquartile range 3-4). Surgeons that adhered additionally reported "logistical challenges of prescribing" as the greatest implementation barrier.

CONCLUSION

Surgeons who remain apprehensive about postdischarge venous thromboembolism prophylaxis cite poor evidence and cost of the medication as the major barriers. Adherence was higher among hepatobiliary surgeons and at hospitals with existing venous thromboembolism-prophylaxis programs.

Double Blind Pilot Randomized Trial Comparing Extended Anticoagulation to Placebo Following Major Lung Resection for Cancer

Venous thromboembolism (VTE), which comprises pulmonary embolus (PE) and deep vein thrombosis (DVT), is a significant cause of postoperative morbidity and mortality. This pilot randomized control trial (RCT) evaluated the feasibility of a full-scale RCT investigating extended thromboprophylaxis in patients undergoing oncological lung resections. Patients undergoing oncological lung resections in 2 tertiary centers received in-hospital, thromboprophylaxis and were randomized to receive post-discharge low-molecular-weight heparin (LMWH) or placebo injections once-daily for 30 days. At 30 days postoperatively, all patients underwent chest computed tomography with PE protocol and bilateral leg venous ultrasound. Primary outcomes included feasibility and safety; VTE incidence and 90-day survival were secondary outcomes. Between December 2015 and June 2018, 619 patients were screened, of whom 62.7% (165/263) of eligible patients consented to participate, and 133 (81%) were randomized. One-hundred and 3 patients, (77.4%), completed the 90-day study follow-up. Reasons for non-participation pre-randomization included patient discomfort and LMWH/placebo administration challenges. Post-randomization withdrawals were due to patient preference, surgeon preference and minor adverse events. Six asymptomatic VTE events (5 PE and 1 DVT) were detected within 30 days (3 in each group), for an overall incidence of 7%. There were 3 minor and no major adverse events. This study is the first to demonstrate the feasibility and safety of a full-scale extended thromboprophylaxis RCT in thoracic surgical oncology. Our results demonstrate that, while recruitment and retention rates were modest, the study design is feasible and with minimal adverse events and no intervention-related mortality.

Incidence and Risk of Various Types of Arterial Thromboembolism in Patients With Cancer

OBJECTIVE

To describe the temporal association and identify risk factors between cancer diagnosis and various types of arterial thromboembolism (ATE).

PATIENTS AND METHODS

We inquired an aggregated electronic health record database (Explorys, IBM Corp., Armonk, New York) and identified patients with cancer from January 1999 to October 2019, with various types of ATE, including myocardial infarction, acute ischemic stroke, acute limb ischemia, acute mesenteric ischemia, acute renal infarction, and retinal artery occlusion. We investigated the temporal relationship between cancer diagnosis and ATE events by examining the incidence ratio (IR) of ATE before and after diagnosis of cancer.

RESULTS

We identified 305,384 patients with cancer and ATE. The 30-day interval IR of total ATE was elevated shortly before and after cancer diagnosis, which was consistent among different ATE and cancer types. The incidence was highest within a 330-day window (90 days before and 240 days after cancer diagnosis), and IR peaked at 13.9 (95% confidence interval [CI], 13.6 to 14.2) in the first 30 days following diagnosis of cancer. Compared with patients with cancer who never developed ATE, patients with ATE had more cardiovascular risk factors at baseline. Patients with brain cancer, lung cancer, colorectal cancer, and pancreatic cancer had the highest risk of developing ATE, whereas ATE type was anatomically associated with cancer type.

CONCLUSION

In this observational study of an aggregated US patient population, those with newly diagnosed cancer had increased risk of ATE events. This risk was most elevated in a 330-day window around cancer diagnosis and was consistent across different types of ATE and cancer.

American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

BACKGROUND

Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer.

CONCLUSIONS

Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.

Retrospective Review of Prescribing Patterns in Cancer-Associated Thrombosis: A Single Center Experience in Edmonton, Alberta, Canada

Low molecular weight heparin (LMWH) is the standard of care for treating cancer-associated thrombosis (CAT), although new evidence for direct oral anticoagulants (DOACs) supports use in specific cancer populations. In this retrospective review at a specialty CAT clinic from 2016 to 2019, we report the use of anticoagulants (LMWH, DOACs, warfarin, anticoagulant class change) in the acute and chronic phases of CAT and compare use before/after publication of the Hokusai-VTE Cancer trial. Death, venous thromboembolism (VTE) recurrence and bleeding was also reported. Of the 221 included, median age was 69 years, with 57.5% having metastatic disease. In the acute phase, 80.1% were prescribed LMWH, 4.1% DOAC, and 14.5% had an anticoagulant class change (LMWH to DOAC; 78.1%). In the chronic phase, 35.8% were prescribed LMWH, 11.3% DOAC, and 42.9% had an anticoagulant class change (LMWH to DOAC; 90.1%). Use of DOACs in the acute and chronic phase prior to the Hokusai-VTE trial was 1.0% and 2.0%, respectively, and following publication was 6.8% and 19.6%. Death occurred for 22.6% patients, recurrent VTE in 7.2%, and bleeding in 5.0%. DOAC use is increasing with time; real-world data may help to guide optimization of the care of complex patients.

Engineering of biomaterials for tumor modeling

Development of biomaterials mimicking tumor and its microenvironment has recently emerged for the use of drug discovery, precision medicine, and cancer biology. These biomimetic models have developed by reconstituting tumor and stroma cells within the 3D extracellular matrix. The models are recently extended to recapitulate the in vivo tumor microenvironment, including biological, chemical, and mechanical conditions tailored for specific cancer type and its microenvironment. In spite of the recent emergence of various innovative engineered tumor models, many of these models are still early stage to be adapted for cancer research. In this article, we review the current status of biomaterials engineering for tumor models considering three main aspects - cellular engineering, matrix engineering, and engineering for microenvironmental conditions. Considering cancer-specific variability in these aspects, our discussion is focused on pancreatic cancer, specifically pancreatic ductal adenocarcinoma (PDAC). In addition, we further discussed the current challenges and future opportunities to create reliable and relevant tumor models.

Treatment of cancer-associated thrombosis: The evolution of anticoagulant choice and clinical insights into practical management

Low-molecular-weight heparin (LMWH) therapy is recommended over vitamin K antagonists (VKAs) for the treatment of cancer-associated thrombosis (CAT) and extended therapy is recommended in those with active cancer to prevent recurrent thrombosis. However, the inconvenience of daily subcutaneous injections and the cost of LMWH therapy hinder long-term use. Observational data demonstrate that persistence with LMWH therapy is low in clinical practice and that many patients are switched to oral alternatives - namely VKAs and direct oral anticoagulants (DOACs). Recently, the efficacy and safety of apixaban, edoxaban, and rivaroxaban versus LMWH therapy for the treatment of CAT have been demonstrated in randomized trials. This review provides a critical evaluation of studies with DOACs in this setting and an update on the guidance regarding anticoagulant use for the treatment of CAT. In recognition of the heterogeneity of patients with cancer and the challenges of CAT, patient cases with expert clinical perspectives are presented.

Prevention and treatment of cancer-associated thrombosis

Cancer is a hypercoagulable state with an associated increased risk of venous thromboembolism (vte) that is further amplified in individuals who undergo chemotherapy. Compared with patients having cancer alone or vte alone, patients who develop cancer-associated vte have a significantly poorer prognosis. The risks of recurrent vte despite appropriate anticoagulation therapy and of bleeding are also higher in patients with cancer than in those without. For those reasons, the prevention and appropriate management of cancer-associated thrombosis is of paramount importance. Although low-molecular-weight heparin has been the standard of care for the prevention and treatment of cancer-associated thrombosis, direct oral anticoagulants are increasingly being adopted as an effective and safe alternative.

Post-discharge venous thromboembolism after pancreatectomy for malignancy: Predicting risk based on preoperative, intraoperative, and postoperative factors

BACKGROUND AND OBJECTIVES

Extended chemoprophylaxis is recommended for high-risk patients following pancreatectomy for malignancy. However, quantifying risk remains difficult. We sought to (a) identify factors associated with post-discharge venous thromboembolism (VTE) following pancreatectomy for malignancy and (b) develop a post-discharge VTE risk calculator to identify high-risk patients.

METHODS

Patients who underwent pancreatectomy for malignant histology from 2014 to 2018 were identified from the ACS NSQIP pancreatectomy procedure targeted dataset. Preoperative, intraoperative, and postoperative factors known at hospital discharge were evaluated for association with post-discharge VTE via multivariable logistic regression. A post-discharge VTE risk calculator was developed and validated.

RESULTS

Of 19 340 analyzed patients, 280 (1.5%) developed post-discharge VTE. Post-discharge VTE was associated with increasing body mass index (BMI; eg, morbidly obese BMI odds ratio [OR]: 1.99 [95% confidence interval {CI}: 1.30-3.02] vs normal BMI), procedure type (distal pancreatectomy OR: 1.47 [95% CI: 1.02-2.12] vs pancreaticoduodenectomy), pancreatic fistula (OR: 1.59 [95% CI: 1.19-2.13]) and delayed gastric emptying (OR: 1.81 [95% CI: 1.29-2.52]). Patients' predicted probability of post-discharge VTE ranged from 0.7% to 9.0%. Twenty iterations of 10-fold cross-validation demonstrated internal validity.

CONCLUSIONS

Preoperative, intraoperative, and postoperative factors were associated with post-discharge VTE following pancreatectomy for malignancy. This post-discharge VTE risk calculator allows for quantification of individual post-discharge VTE risk, which ranged from 0.7% to 9.0%.

Rationale, design and methodology of TESEO study: a registry of thrombosis and neoplasia of SEOM (Spanish Society of Medical Oncology)

BACKGROUND AND RATIONALE

Thromboembolic complications are a serious, preventable and common event in cancer patients that contributes to increasing morbidity and mortality. Despite increasing knowledge on cancer-associated thrombosis (CAT), there are still several aspects of diagnosis, clinical management, treatment and prognosis with uncertainties that are under-represented in randomized clinical trials. For this reason, the Spanish Society of Medical Oncology (SEOM) launched in June 2018 a registry of CAT.

METHODS/DESIGN

TESEO is an ongoing prospective, non-interventional, multicentric study in consecutive cancer patients with newly diagnosed of thromboembolic event (TEE). Eligibility criteria include being  > 18 years with a histologically confirmed diagnosis of cancer and a symptomatic or incidental TEE confirmed with an imaging technique in the previous month or any time after the cancer diagnosis and signing of informed consent. The study consists of two types of integrated but independent prospective registries. Regular CAT sub-registry includes information on patient's cancer´s characteristics, anticoagulant treatment provided and outcome data. Special CAT sub-registry includes variables related to special situations of CAT that comprise patients with severe kidney failure, thrombocytopenia, high risk of bleeding related to the cancer or with coexistence of bleeding and patients who receive new treatments such a targeted therapy, antiangiogenics agents and immunotherapy. The registry considers the status of the cancer and the time to assess how the prognosis is changed based on when the thrombus occurs. Some outcomes such as rethrombosis, major bleeding, tumor progression and survival will be valued in various time intervals including 1, 3, 6 and 12 months after the even in the first year; and then every 6 months until the patient's death.

RESULTS

After 18 months and with 35 centers and researchers, the registry has 1128 patients.

CONCLUSION

TESEO registry will provide clinical real-world evidence for prevention, treatment and complications of CAT in different scenarios that are under-represented in randomized clinical trials.

The Abnormal Expression of miR-205-5p, miR-195-5p, and VEGF-A in Human Cervical Cancer Is Related to the Treatment of Venous Thromboembolism

Background

Low molecular heparin (LWMH) therapy can prevent the occurrence of VTE in tumor patients and may have a direct antitumor effect. However, the expression pattern of VEGF-A and microRNAs was less reported in cervical cancer subjects who received concurrent chemoradiotherapy (CCRT) or received anticoagulant treatment with low molecular weight heparin (LWMH) after CCRT (CCRT+LWMH).

Methods

In this study, 30 cervical cancer subjects treated with CCRT and 30 cervical cancer patients treated with CCRT+LWMH were enrolled. We screened five miRNAs (miR-15a-5p, miR-16-5p, miR-29a-3p, miR-195-5p, and miR-205-5p), which have multiple binding sites with VEGF-A and are highly expressed in serum of patients with cervical cancer, by RT-qPCR. The expression level of VEGF-A was also detected by RT-qPCR and ELISA. Statistical methods were used for difference and correlation analyses.

Results

We observed the curative effect in the two treatment methods. In the CCRT group, the total effective rate was 60.00%, and in the CCRT+LWMT group, the total effective rate was 83.33% (P = 0.013, χ² = 6.129). Additionally, the serum levels of VEGF-A in the CCRT+LWMH group were downregulated, relative to the CCRT group (P < 0.05), and VEGF-A in serum was significantly positively correlated with venous thromboembolism (VTE) (r = 2.134, P = 0.035). Only miR-205-5p and miR-195-5p were upregulated in CCRT+LWMH, relative to CCRT (P < 0.05). In serum of patients with cervical cancer after CCRT+LWMH treatment, there was no significant correlation between VEGF-A and miR-15a-5p (r = −0.132, P = 0.209), miR-16-5p (r = −0.205, P = 0.311), or miR-29a-3p (r = −0.029, P = 0.662), but VEGF-A was significantly negatively correlated with miR-195-5p (r = −0.396, P = 0.040) and miR-205-5p (r = −0.315, P = 0.032). Furthermore, VTE was also significantly negatively correlated with miR-195-5p (r = −0.412, P = 0.031) and miR-205-5p (r = −0.123, P = 0.044).

Conclusion

These data revealed roles for VEGF-A and these miRNAs as potential biomarkers in cervical cancer patients with VTE, which exhibited usage potential in the treatment of venous thromboembolism.

Latest advances in preventing thromboembolic disease in the ambulatory oncology patient

Venous thromboembolism (VTE) is often cited as a major cause of death and morbidity in cancer patients. Even a non-lethal VTE causes distress and is commonly perceived by patients as a set-back in the cancer journey and a threat to the cancer treatment. It is also known that the risk of VTE varies between cancers (cancer-related risk factors), between patients (patient-related risk factors), and also within the cancer journey of a single patient. Risk can increase during treatments like surgery and chemotherapy and decline during remission. Neither the low molecular weight heparins nor the vitamin K analogues have gained an established role in thromboprevention guidance other than in 'the high risk' patient, who remains a rather ambiguous entity. The recently published randomised studies of rivaroxaban and apixaban in moderate- to high-risk thrombosis patients, assigned by the Khorana Risk Score, has seen the inclusion of direct oral anticoagulants (DOACs) in recent guidelines (e.g. the American Society of Clinical Oncology 2019 guidelines) for this indication. The ease of administration and the demonstrated greater patient adherence to oral agents has heightened the expectation that a practice-changing thromboprevention study in cancer patients should be realizable. However, key unmet needs that pose familiar challenges remain and as yet do not have satisfactory solutions. Anticoagulants carry risks of bleeding that are higher in the cancer population. There is therefore the challenge of sufficient risk reduction of VTE from the intervention balanced against the number of patients that may be harmed from bleeding. There is also the challenge of penetrating the risk threshold beyond which oncologists would deem thromboprevention a clinically meaningful praxis. Thus, identifying the high-risk groups of patients or targeting the length or timing of the thromboprevention to when the risks are highest are major questions that remain the subject of ongoing research. Notably all this is taking place against a backdrop of changing therapeutics for many cancers (e.g. targeted agents, checkpoint inhibitors and combinations) and their assorted impact on VTE incidence. In this review, past data for the ambulatory cancer patient are summarised, the latest evidence for the direct oral anticoagulants apixaban and rivaroxaban are analysed and the challenges of identifying the high-risk patients that have the greater chance of benefiting from thromboprophylaxis are discussed.

Cancer-associated venous thromboembolism: Treatment and prevention with rivaroxaban

Cancer-associated venous thromboembolism (VTE) is a frequent, potentially life-threatening event that complicates cancer management. Anticoagulants are the cornerstone of therapy for the treatment and prevention of cancer-associated thrombosis (CAT); factor Xa-inhibiting direct oral anticoagulants (DOACs; apixaban, edoxaban, and rivaroxaban), which have long been recommended for the treatment of VTE in patients without cancer, have been investigated in this setting. The first randomized comparisons of DOACs against low-molecular-weight heparin for the treatment of CAT indicated that DOACs are efficacious in this setting, with findings reflected in recent updates to published guidance on CAT treatment. However, the higher risk of bleeding events (particularly in the gastrointestinal tract) with DOACs highlights the need for appropriate patient selection. Further insights will be gained from additional studies that are ongoing or awaiting publication. The efficacy and safety of DOAC thromboprophylaxis in ambulatory patients with cancer at a high risk of VTE have also been assessed in placebo-controlled randomized controlled trials of apixaban and rivaroxaban. Both studies showed efficacy benefits with DOACs, but both studies also showed a nonsignificant increase in major bleeding events while on treatment. This review summarizes the evidence base for rivaroxaban use in CAT, the patient profile potentially most suited to DOAC use, and ongoing controversies under investigation. We also describe ongoing studies from the CALLISTO (Cancer Associated thrombosis-expLoring soLutions for patients through Treatment and Prevention with RivarOxaban) program, which comprises several randomized clinical trials and real-world evidence studies, including investigator-initiated research.