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Qian X, Fu M, Zheng J, Zhou J, Zhou J. Driver Genes Associated With the Incidence of Venous Thromboembolism in Patients With Non-Small-Cell Lung Cancer: A Systematic Review and Meta-Analysis. Front Oncol 2021; 11:680191. [PMID: 33996610 PMCID: PMC8117344 DOI: 10.3389/fonc.2021.680191] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/06/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The association between driver genes and the incidence of thromboembolic events (TEs) in patients diagnosed with non-small-cell lung cancer (NSCLC) needs to be quantified to guide clinical management. METHODS We interrogated PubMed, Embase, Web of Science and Cochrane library databases for terms related to venous thromboembolism (VTE) and arterial thromboembolism (ATE) in patients diagnosed with non-small-cell lung cancer harboring driver genes. This search was conducted for studies published between 1 January, 2000 and 31 December, 2020. A random-effects meta-analysis was performed to analyze the pooled incidence and odds ratios of VTE in patients with different driver genes. RESULTS Of the 2,742 citations identified, a total of 25 studies that included 21,156 patients met eligibility criteria. The overall pooled incidence of VTE in patients with driver genes was 23% (95% CI 18-29). Patients with ROS1 rearrangements had the highest incidence of VTE (37%, 95%CI 23-52). ALK rearrangements were associated with increased VTE risks (OR=2.08,95% CI 1.69-2.55), with the second highest incidence of VTE (27%, 95%CI 20-35). Both groups of patients with EGFR and KRAS mutations did not show a significantly increased risk for VTE (OR=1.33, 95% CI 0.75-2.34; OR=1.31, 95% CI 0.40-4.28). CONCLUSIONS ALK rearrangements were shown to be associated with increased VTE risks in patients diagnosed with non-small lung cancer, while there was no significant relation observed between VTE risks and EGFR or KRAS mutations in lung cancer patients.
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Affiliation(s)
| | | | | | | | - Jianying Zhou
- Department of Respiratory Disease, Thoracic Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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2
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 426] [Impact Index Per Article: 142.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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3
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Du J, Wu B. New Oral Anticoagulants for Thromboprophylaxis in Patients with Cancer Receiving Chemotherapy: An Economic Evaluation in a Chinese Setting. Clin Drug Investig 2020; 40:653-663. [PMID: 32445169 DOI: 10.1007/s40261-020-00926-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Recent trials showed that thromboprophylaxis with new oral anticoagulants (NOACs) is effective and safe in patients with cancer initiating chemotherapy. However, the cost effectiveness of NOACs is unknown. The objective of this study was to compare the cost effectiveness of preventing venous thromboembolism with NOACs with no thromboprophylaxis for patients with cancer initiating systemic chemotherapy from the perspective of the Chinese healthcare system. METHODS A decision analytical model consisting of both acute and chronic venous thromboembolism complications was used to assess the cost effectiveness of thromboprophylaxis with NOACs vs no thromboprophylaxis. The key clinical data were derived from the CASSINI and AVERT trials. Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for the two strategies. Scenario and sensitivity analyses were performed. RESULTS Compared with no thromboprophylaxis, NOACs gained 0.072 QALY at an incremental cost of $US930, leading to an ICER of 12,919/QALY in patients with Khorana scores ≥ 2 by pooling the data from the CASSINI and AVERT trials. Among patients confirmed with no deep-vein thrombosis before thromboprophylaxis (the CASSINI trial) and patients without deep-vein thrombosis screening before thromboprophylaxis (the AVERT trial), the ICERs were $70,897/QALY and $87,204/QALY, respectively. The probability of NOACs being cost effective was 42% at a willingness to pay of $10,276/QALY. The ICER was sensitive to the relative risks of death and asymptomatic venous thromboembolism between NOACs and no thromboprophylaxis and the cost of NOACs. CONCLUSIONS Thromboprophylaxis with NOACs is not likely to be cost effective in patients initiating chemotherapy in the Chinese context. The decision about thromboprophylaxis should be tailored based on the survival of patients with cancer, the risks of venous thromboembolism, and major bleeding.
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Affiliation(s)
- Jiangyang Du
- Medical Decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Jiangyue Road 2000, Shanghai, 201112, China
| | - Bin Wu
- Medical Decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Jiangyue Road 2000, Shanghai, 201112, China.
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4
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Dallos MC, Eisenberger AB, Bates SE. Prevention of Venous Thromboembolism in Pancreatic Cancer: Breaking Down a Complex Clinical Dilemma. Oncologist 2020; 25:132-139. [PMID: 32043768 PMCID: PMC7011653 DOI: 10.1634/theoncologist.2019-0264] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/31/2019] [Indexed: 12/14/2022] Open
Abstract
Venous thromboembolism (VTE) frequently occurs in patients with cancer, and particularly those with pancreatic ductal adenocarcinoma (PDAC). Therapeutic anticoagulation with either low-molecular-weight heparin or a direct oral anticoagulant is clearly beneficial in patients who develop a VTE. However, whether thromboprophylaxis improves patient outcomes remains unclear. Studies assessing this risk show a 10%-25% risk of VTE, with reduction to 5%-10% with thromboprophylaxis but no impact on survival. To aid in the risk stratification of patients, several tools have been developed to identify those at highest risk for a VTE event. However, the clinical application of these risk stratification models has been limited, and most patients, even those at the highest risk, will never have a VTE event. New oral anticoagulants have greatly improved the feasibility of prophylaxis but do show increased risk of bleeding in patients with the underlying gastrointestinal dysfunction frequently found in patients with pancreatic cancer. Recently, several completed clinical trials shed new light on this complicated risk versus benefit decision. Here, we present this recent evidence and discuss important considerations for the clinician in determining whether to initiate thromboprophylaxis in patients with PDAC. IMPLICATIONS FOR PRACTICE: Given the high risk of venous thromboembolism in patients with pancreatic adenocarcinoma (PDAC), whether to initiate prophylactic anticoagulation is a complex clinical decision. This review discusses recent evidence regarding the risk stratification and treatment options for thromboprophylaxis in patients with PDAC, with the goal of providing practicing clinicians with updates on recent developments in the field. This article also highlights important considerations for individualizing the treatment approach for a given patient given the lack of general consensus of uniform recommendations for this patient population.
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Affiliation(s)
- Matthew C. Dallos
- Division of Hematology/Oncology, Columbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Andrew B. Eisenberger
- Division of Hematology/Oncology, Columbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Susan E. Bates
- Division of Hematology/Oncology, Columbia University Irving Medical CenterNew YorkNew YorkUSA
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5
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Chen H, Tao R, Zhao H, Jiang J, Yang J. Prevention of venous thromboembolism in patients with cancer with direct oral anticoagulants: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19000. [PMID: 32000440 PMCID: PMC7004711 DOI: 10.1097/md.0000000000019000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with cancer are of a high level risk of venous thromboembolism (VTE). Low molecular weight heparin (LMWH) is recommended as the normal treatment for cancer-associated venous thrombosis. Recently, some studies suggest that patients with cancer-associated venous thrombosis can get a good efficacy and safety profile from treating with direct oral anticoagulants (DOACs) compared with other anticoagulants. However, when it comes to the efficacy of DAOCs in preventing VTE in patient with cancer, the data are limited. Thus, we performed such a meta-analysis to determine the efficacy and safety of DOACs in preventing VTE in patient with cancer compared with LMWHs. METHODS Medline/PubMed and CENTRAL (The Cochrane Central Register of Controlled Trials) were systematically searched for relevant studies. For each trial, data on VTE, major bleeding, or bleeding were extracted by 2 reviewers independently. Pooled risk ratios (RRs) were calculated by using Review Manager 5.3 software and the significance was determined by the Z test. RESULTS A total of 6 studies with 7185 patients were included in our meta-analysis. DOACs (RR = 0.55, 95% confidence interval [95%CI]: 0.34-0.90, I = 31%) had a similar prevention effect of VTE to LMWH (RR = 0.59, 95% CI: 0.37-0.95, I = 59%). DOACs (RR = 1.52, 95% CI: 0.99-2.33, I = 0%) yielded a similar bleeding occurrence rate compared with LMWH (RR = 1.35, 95% CI: 1.07-1.70, I = 35%). DOACs (RR = 1.95, 95% CI: 0.88-4.30, I = 0%) showed a sight higher major bleeding occurrence rate than LMWH (RR = 1.38, 95% CI: 0.88-2.14, I = 0%). CONCLUSION DOACs show comparable efficacy to LMWH in cancer patients without VTE with a slightly higher major bleeding occurrence rate. DOACs are inclined to be an alternative thromboprophylaxis strategy in cancer patients as they have superiorities compared to traditional anticoagulation agents. Further studies are still demanded as exiting relevant researches are limited.
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Affiliation(s)
- Hailong Chen
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Rui Tao
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Hui Zhao
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Jianjun Jiang
- Department of Respiratory Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jin Yang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
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Nimesh N, Verma SK, Gupta SK. Cortical blindness due to cerebral infarct in advanced pancreatic cancer. BMJ Case Rep 2019; 12:12/7/e223843. [DOI: 10.1136/bcr-2017-223843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A 65-year-old man, a known case of advanced pancreatic cancer on cisplatin and gemcitabine-based chemotherapy, presented with sudden bilateral painless loss of vision with altered sensorium. Clinical examination showed a normal pupillary light reaction, normal anterior segment and normal fundus. MRI brain showed bilateral parieto-occipital infarct. This report highlights the incidence of cortical blindness due to thromboembolism at the cerebral level in pancreatic cancer. Cerebral ischaemic events occur at an advanced stage of pancreatic cancer already diagnosed at stroke onset and portend a poor prognosis. Anticoagulation therapy, especially low molecular weight heparin, remains the best strategy to prevent recurrences.
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Tafur AJ, Fuentes H, Caprini JA, Rivas A, Uresandi F, Duce R, Lopez-Reyes R, Visona A, Merah A, Monreal M. Predictors of Early Mortality in Cancer-Associated Thrombosis: Analysis of the RIETE Database. TH OPEN 2018; 2:e158-e166. [PMID: 31249939 PMCID: PMC6524871 DOI: 10.1055/s-0038-1642022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/13/2018] [Indexed: 12/13/2022] Open
Abstract
Cancer-associated thrombosis (CT) carries a high, heterogeneous, and poorly predicted likelihood of mortality. Thus, we aimed to define predictors of 30-day mortality in 10,025 patients with CT. In a randomly selected derivation cohort, we used recursive partitioning analysis to detect variables that select for a risk of mortality within 30 days. In a validation cohort, we evaluated our results using Cochran–Armitage test. The most common types of cancer were lung (16%), breast (14%), and colorectal (14%); median age was 69 years (range, 14–101); most had metastatic disease (63%); 13% of patients died within 30 days. In the derivation cohort (
n
= 6,660), a white blood cell (WBC) count in the highest quartile predicted early mortality (odds ratio, 7.8; 95% confidence interval [CI], 4.6–13.1); and the presence of metastatic disease, pulmonary embolism (PE), and immobility defined the risk of those with normal WBC count. We defined death risk according four sequential questions: (1) Does the patient have an elevated WBC count? (Yes, group D). (2) If no, does the patient have metastasis? (No, group A). (3) If yes, is the patient immobile? (Yes, group D). (4) If no, does the patient have a PE? (Yes, group C; no, group B). In the validation cohort (
n
= 3,365), the 30-day risk of death was 2.9% in group A (95% CI, 1.9–4.3), compared with 25% in group D (95% CI, 22.5–27.5), and there was a rate escalation between groups (
p
for trend < 0.01). In conclusion, with four sequential questions, the risk of death in CT can be easily stratified. An elevated WBC count at baseline predicted 30-day mortality better than metastases, PE, or immobility.
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Affiliation(s)
- Alfonso J Tafur
- NorthShore University HealthSystem, Evanston, Illinois, United States
| | - Harry Fuentes
- John Stroger Cook County Hospital, Chicago, Illinois, United States
| | - Joseph A Caprini
- NorthShore University HealthSystem, Evanston, Illinois, United States
| | | | - F Uresandi
- Hospital de Cruces, Barakaldo, Vizcaya, Spain
| | | | | | - Adriana Visona
- Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
| | - Adel Merah
- Université Jean-Monnet, Service de Medecine Vasculaire et Therapeutique, CHU de Saint Etienne, Saint-Etienne, France
| | - Manuel Monreal
- Hospital Universitario Germans Trias i Pujol de Badalona, Universidad Católica de Murcia, Barcelona, Spain
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8
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Nestler T, Huber J, Laury AM, Isbarn H, Heidenreich A, Schmelz HU, Ruf CG. Thromboprophylaxis and the route of administration of chemotherapy in testicular cancer patients in German-speaking countries. World J Urol 2018; 36:913-920. [PMID: 29417289 DOI: 10.1007/s00345-018-2222-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 02/01/2018] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Due to the excellent cure rates for testicular cancer (TC), focus has shifted towards decreasing therapy-related morbidities. Thrombosis is a frequent complication of cisplatin chemotherapy. Furthermore, the optimal route of administration for chemotherapy is still under debate. The purpose of this study was to assess the patterns of care concerning dosing and duration of thromboprophylaxis currently utilized in TC patients in German-speaking countries as well as the route of chemotherapy administration. METHODS A standardized questionnaire was sent to all members of the German TC Study Group (GTCSG) and to all the urological university hospitals in Germany. The questionnaire was also sent to the oncologic clinics at those universities where urologists do not administer chemotherapy. RESULTS The response rate was 87% (55/63). Prophylactic anticoagulation with low-molecular-weight heparin (LMWH) was administered in 94% of the clinics. The dosing of LMWH was prophylactic (85%), high prophylactic (adjusted to bodyweight) (7%), or risk adapted (9%). After completion of chemotherapy, anticoagulation was continued in 15 clinics (33%) for 2 to 24 weeks, while the remainder stopped the LMWH upon cessation of chemotherapy. Chemotherapy was administered via central venous access in 59%, peripheral IV in 27%, or both in 14% of the clinics. CONCLUSIONS Most of the institutions performed some form of thromboprophylaxis, although the modes of application varied by institution type and amongst the urologists and oncologists. Prospective studies are needed to evaluate the incidence, date of occurrence, and risk factors of venous thrombosis during TC chemotherapy to provide a recommendation concerning prophylactic anticoagulation.
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Affiliation(s)
- Tim Nestler
- Department of Urology, Federal Armed Services Hospital Koblenz, Koblenz, Germany. .,Department of Urology, University Hospital Cologne, Cologne, Germany.
| | - Johannes Huber
- Department of Urology, University Hospital Dresden, Dresden, Germany
| | - Adrienne M Laury
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium (SAUSHEC), Fort Sam Houston, Texas, USA
| | - Hendrik Isbarn
- Martini-Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Heidenreich
- Department of Urology, University Hospital Cologne, Cologne, Germany
| | - Hans U Schmelz
- Department of Urology, Federal Armed Services Hospital Koblenz, Koblenz, Germany
| | - Christian G Ruf
- Department of Urology, Federal Armed Services Hospital Koblenz, Koblenz, Germany
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Akl EA, Kahale LA, Hakoum MB, Matar CF, Sperati F, Barba M, Yosuico VED, Terrenato I, Synnot A, Schünemann H. Parenteral anticoagulation in ambulatory patients with cancer. Cochrane Database Syst Rev 2017; 9:CD006652. [PMID: 28892556 PMCID: PMC6419241 DOI: 10.1002/14651858.cd006652.pub5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Anticoagulation may improve survival in patients with cancer through a speculated anti-tumour effect, in addition to the antithrombotic effect, although may increase the risk of bleeding. OBJECTIVES To evaluate the efficacy and safety of parenteral anticoagulants in ambulatory patients with cancer who, typically, are undergoing chemotherapy, hormonal therapy, immunotherapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation. SEARCH METHODS A comprehensive search included (1) a major electronic search (February 2016) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 1), MEDLINE (1946 to February 2016; accessed via OVID) and Embase (1980 to February 2016; accessed via OVID); (2) handsearching of conference proceedings; (3) checking of references of included studies; (4) use of the 'related citation' feature in PubMed and (5) a search for ongoing studies in trial registries. As part of the living systematic review approach, we are running searches continually and we will incorporate new evidence rapidly after it is identified. This update of the systematic review is based on the findings of a literature search conducted on 14 August, 2017. SELECTION CRITERIA Randomized controlled trials (RCTs) assessing the benefits and harms of parenteral anticoagulation in ambulatory patients with cancer. Typically, these patients are undergoing chemotherapy, hormonal therapy, immunotherapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation. DATA COLLECTION AND ANALYSIS Using a standardized form we extracted data in duplicate on study design, participants, interventions outcomes of interest, and risk of bias. Outcomes of interested included all-cause mortality, symptomatic venous thromboembolism (VTE), symptomatic deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, minor bleeding, and quality of life. We assessed the certainty of evidence for each outcome using the GRADE approach (GRADE handbook). MAIN RESULTS Of 6947 identified citations, 18 RCTs fulfilled the eligibility criteria. These trials enrolled 9575 participants. Trial registries' searches identified nine registered but unpublished trials, two of which were labeled as 'ongoing trials'. In all included RCTs, the intervention consisted of heparin (either unfractionated heparin or low molecular weight heparin). Overall, heparin appears to have no effect on mortality at 12 months (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.93 to 1.03; risk difference (RD) 10 fewer per 1000; 95% CI 35 fewer to 15 more; moderate certainty of evidence) and mortality at 24 months (RR 0.99; 95% CI 0.96 to 1.01; RD 8 fewer per 1000; 95% CI 31 fewer to 8 more; moderate certainty of evidence). Heparin therapy reduces the risk of symptomatic VTE (RR 0.56; 95% CI 0.47 to 0.68; RD 30 fewer per 1000; 95% CI 36 fewer to 22 fewer; high certainty of evidence), while it increases in the risks of major bleeding (RR 1.30; 95% 0.94 to 1.79; RD 4 more per 1000; 95% CI 1 fewer to 11 more; moderate certainty of evidence) and minor bleeding (RR 1.70; 95% 1.13 to 2.55; RD 17 more per 1000; 95% CI 3 more to 37 more; high certainty of evidence). Results failed to confirm or to exclude a beneficial or detrimental effect of heparin on thrombocytopenia (RR 0.69; 95% CI 0.37 to 1.27; RD 33 fewer per 1000; 95% CI 66 fewer to 28 more; moderate certainty of evidence); quality of life (moderate certainty of evidence). AUTHORS' CONCLUSIONS Heparin appears to have no effect on mortality at 12 months and 24 months. It reduces symptomatic VTE and likely increases major and minor bleeding. Future research should further investigate the survival benefit of different types of anticoagulants in patients with different types and stages of cancer. The decision for a patient with cancer to start heparin therapy should balance the benefits and downsides, and should integrate the patient's values and preferences.Editorial note:This is a living systematic review. Living systematic reviews offer a new approach to review updating in which the review is continually updated, incorporating relevant new evidence, as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Elie A Akl
- Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh St, Beirut, Lebanon
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10
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Fuentes HE, Paz LH, Wang Y, Oramas DM, Simons CR, Tafur AJ. Performance of Current Thromboembolism Risk Assessment Tools in Patients With Gastric Cancer and Validity After First Treatment. Clin Appl Thromb Hemost 2017; 24:790-796. [PMID: 28884610 DOI: 10.1177/1076029617726599] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Patients with gastric cancer (GC) are at higher risk of thromboembolism when compared to other solid tumors. We aim to determine the predictive performance of current venous thromboembolism (VTE) predictive tools and their variability and validity after first treatment. Single institution cohort of GC-treated patients (2010*15). We abstracted predictive tools, validated for VTE prediction in patient with cancer; including the Khorana Score (KRS), platelet to lymphocyte ratio (PLR), and neutrophil to lymphocyte ratio (NLR). The primary outcome was CAT prediction. We included 112 patients who were predominantly men (66%), 58 (51-64)-year-olds, with adenocarcinoma (84%) and advanced disease (59%). The median follow-up was 21.3 months (9.5-42.6). The VTE occurrence was 12%. The median time from diagnosis to VTE occurrence was 59 days (36-258). In our cohort, performance status (PS; hazard ratio [HR], 8.02; 95% confidence interval [CI], 2.37-27.14; P < .01) was an independent predictor of VTE whereas KRS (univariate HR, 2.3; 95% CI, 0.7-7.4; P = .17), PLR (univariate HR, 0.8; 95% CI, 0.2-3.1; P = .8), and NLR (univariate HR, 0.8; 95% CI, 0.3-2.5; P = .8) at baseline were not associated with VTE risk. The posttreatment KRS was an independent predictor of VTE (HR, 3.69; 95% CI, 1.17-11.65; P = .25) along with PS (HR, 7.58; 95% CI, 2.27-25.33; P = .01). Posttreatment KRS appears as a valid tool to identify patients with GC at high risk of VTE after first cancer treatment.
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Affiliation(s)
- Harry E Fuentes
- 1 Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - L H Paz
- 1 Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Y Wang
- 1 Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - D M Oramas
- 2 Department of Pathology, University of Illinois at Chicago, Chicago, IL, USA
| | - C R Simons
- 1 Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - A J Tafur
- 3 Cardiology-Vascular Medicine, Northshore University Healthsystem, Evanston, IL, USA
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11
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Meta-analysis on anticoagulation and prevention of thrombosis and mortality among patients with lung cancer. Thromb Res 2017; 154:28-34. [DOI: 10.1016/j.thromres.2017.03.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/20/2017] [Accepted: 03/29/2017] [Indexed: 12/12/2022]
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Farge D, Bounameaux H, Brenner B, Cajfinger F, Debourdeau P, Khorana AA, Pabinger I, Solymoss S, Douketis J, Kakkar A. International clinical practice guidelines including guidance for direct oral anticoagulants in the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol 2017; 17:e452-e466. [PMID: 27733271 DOI: 10.1016/s1470-2045(16)30369-2] [Citation(s) in RCA: 265] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/13/2016] [Accepted: 07/14/2016] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) is the second leading cause of death in patients with cancer. These patients are at an increased risk of developing VTE and are more likely to have a recurrence of VTE and bleeding while taking anticoagulants. Management of VTE in patients with cancer is a major therapeutic challenge and remains suboptimal worldwide. In 2013, the International Initiative on Thrombosis and Cancer (ITAC-CME), established to reduce the global burden of VTE in patients with cancer, published international guidelines for the treatment and prophylaxis of VTE and central venous catheter-associated thrombosis. The rapid global adoption of direct oral anticoagulants for management of VTE in patients with cancer is an emerging treatment trend that needs to be addressed based on the current level of evidence. In this Review, we provide an update of the ITAC-CME consensus recommendations based on a systematic review of the literature ranked according to the Grading of Recommendations Assessment, Development, and Evaluation scale. These guidelines aim to address in-hospital and outpatient cancer-associated VTE in specific subgroups of patients with cancer.
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Affiliation(s)
- Dominique Farge
- Assistance Publique-Hôpitaux de Paris, Internal Medicine: Autoimmune and Vascular Disease Unit, Saint-Louis Hospital, Paris, France; Sorbonne Paris Cité, Paris 7 Diderot University, Paris, France.
| | - Henri Bounameaux
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Francis Cajfinger
- Assistance Publique-Hôpitaux de Paris, Service d'oncologie, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Internal Medicine, Medical University Vienna, Vienna, Austria
| | - Susan Solymoss
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ajay Kakkar
- Thrombosis Research Institute, London, UK; University College London, London, UK
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Tafur AJ, Caprini JA, Cote L, Trujillo-Santos J, Del Toro J, Garcia-Bragado F, Tolosa C, Barillari G, Visona A, Monreal M. Predictors of active cancer thromboembolic outcomes. RIETE experience of the Khorana score in cancer-associated thrombosis. Thromb Haemost 2017; 117:1192-1198. [PMID: 28276571 DOI: 10.1160/th16-11-0840] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/23/2017] [Indexed: 12/14/2022]
Abstract
Even though the Khorana risk score (KRS) has been validated to predict against the development of VTE among patients with cancer, it has a low positive predictive value. It is also unknown whether the score predicts outcomes in patients with cancer with established VTE. We selected a cohort of patients with active cancer from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry to assess the prognostic value of the KRS at inception in predicting the likelihood of VTE recurrences, major bleeding and mortality during the course of anticoagulant therapy. We analysed 7948 consecutive patients with cancer-associated VTE. Of these, 2253 (28 %) scored 0 points, 4550 (57 %) 1-2 points and 1145 (14 %) scored ≥3 points. During the course of anticoagulation, amongst patient with low, moderate and high risk KRS, the rate of VTE recurrences was of 6.21 (95 %CI: 4.99-7.63), 11.2 (95 %CI: 9.91-12.7) and 19.4 (95 %CI: 15.4-24.1) events per 100 patient-years; the rate of major bleeding of 5.24 (95 %CI: 4.13-6.56), 10.3 (95 %CI: 9.02-11.7) and 19.4 (95 %CI: 15.4-24.1) bleeds per 100 patient-years and the mortality rate of 25.3 (95 %CI: 22.8-28.0), 58.5 (95 %CI: 55.5-61.7) and 120 (95 %CI: 110-131) deaths per 100 patient-years, respectively. The C-statistic was 0.53 (0.50-0.56) for recurrent VTE, 0.56 (95 %CI: 0.54-0.59) for major bleeding and 0.54 (95 %CI: 0.52-0.56) for death. In conclusion, most VTEs occur in patients with low or moderate risk scores. The KRS did not accurately predict VTE recurrence, major bleeding, or mortality among patients with cancer-associated thrombosis.
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Affiliation(s)
- Alfonso J Tafur
- Alfonso J. Tafur, MD, NorthShore University HealthSystem, 9650 Gross Point Road, Suite 4900, Skokie, IL 60076, USA, Tel.: +1 847 663 8050, Fax: +1 224 251 4407, E-mail:
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14
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Iftikhar O, Silva-Palacios F, Cherry M, Mansfield A, Stoner J, Tafur A. Predictors of active cancer thromboembolic outcomes: role of body composition. INT ANGIOL 2017; 36:88-89. [PMID: 28124878 DOI: 10.23736/s0392-9590.16.03668-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Omer Iftikhar
- Cardiovascular Section, Northshore University Health System, Evanston, IL, USA.,Department of Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Federico Silva-Palacios
- Cardiovascular Section, Northshore University Health System, Evanston, IL, USA.,Department of Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Mohamad Cherry
- Cardiovascular Section, Northshore University Health System, Evanston, IL, USA.,Department of Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Aaron Mansfield
- Mayo School of Graduate Medical Education, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Julie Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Alfonso Tafur
- Cardiovascular Section, Northshore University Health System, Evanston, IL, USA -
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Gopalakrishna A, Longo TA, Fantony JJ, Doshi U, Harrison MR, Van Noord M, Inman BA. High rates of venous thromboembolic events in patients undergoing systemic therapy for urothelial carcinoma: A systematic review and meta-analysis. Urol Oncol 2016; 34:407-14. [PMID: 27267581 PMCID: PMC4996725 DOI: 10.1016/j.urolonc.2016.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/27/2016] [Accepted: 05/04/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients undergoing systemic therapy for urothelial carcinoma (UC) are at increased risk for venous thromboembolic (VTE) events. The objective of the current study was to determine the rate of VTE events in patients undergoing systemic therapy for UC and assess factors affecting this rate. METHODS This study was registered with the PROSPERO database (CRD42015025774). We searched Pubmed, MEDLINE, EMBASE, The Cochrane Library, CINAHL, and Web of Science libraries through August 2014. As per PRISMA guidelines, 2 reviewers independently reviewed titles and abstracts. Disagreements were arbitrated by a third reviewer. After full text review, data were abstracted and pooled using a random effects model. Authors were contacted for clarification of data. To determine VTE risk factors, subgroup analyses and meta-regression were conducted. RESULTS We identified 3,635 publications in the initial search, of which 410 met inclusion criteria for full text review. Of these, we were able to obtain data on the outcome of interest for 62 publications. A total of 5,082 patients, of which 77% were male, underwent systemic therapy for UC, with 373 VTE events. The proportion of patients who had had prior surgery, chemotherapy, or radiation was 55%, 25%, and 9%, respectively. Fixed effects and random effects models were used to estimate the VTE rate, yielding event rates of 6.7% and 5.4%, respectively. CONCLUSIONS VTE occurs frequently in patients undergoing systemic therapy for UC. The VTE rate was affected by the country of origin, history of radiation, as well as by the systemic treatment class. The study was limited by the incomplete reporting of all variables of interest.
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Affiliation(s)
| | - Thomas A Longo
- Division of Medical Oncology, Duke University Medical Center, Durham, NC
| | | | - Uma Doshi
- Division of Urology, Duke University Medical Center, Durham, NC
| | - Michael R Harrison
- Division of Medical Oncology, Duke University Medical Center, Durham, NC
| | - Megan Van Noord
- Research and Education Services, Duke University Medical Center, Durham, NC
| | - Brant A Inman
- Division of Urology, Duke University Medical Center, Durham, NC.
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Mansfield A, Tafur AJ, Wang CE, Kourelis TV, Wysokinska EM, Yang P. Predictors of active cancer thromboembolic outcomes: validation of the Khorana score among patients with lung cancer. J Thromb Haemost 2016; 14:1773-8. [PMID: 27273134 PMCID: PMC5035574 DOI: 10.1111/jth.13378] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Indexed: 12/14/2022]
Abstract
UNLABELLED Essentials Venous thromboembolism (VTE) prevention strategies require effective risk assessment models. We sought to validate the Khorana Risk Score (KRS) in patients with lung cancer. A high KRS was not predictive of VTE but was independently associated with all-cause mortality. Our findings stress the need for a lung cancer-specific VTE risk assessment model. SUMMARY Objectives Lung cancer is strongly associated with venous thromboembolism (VTE), but primary prevention against VTE is not a validated management strategy. Risk assessment models will be necessary for efficient implementation of preventative strategies. Materials and methods Utilizing a prospectively collected lung cancer database, we aimed to validate the Khorana Risk Score (KRS) in the prediction of VTE among patients with lung cancer. VTE events were retrospectively identified by reviewers unaware of the clinical prediction score calculation. The association between KRS and the risk of VTE was examined using cumulative incidence function with competing risk models. Mortality prediction was evaluated as a secondary outcome. Results We included 719 patients in our review. The patients were predominantly older men with non-small cell lung cancer and 40% had metastatic disease at inception. The median follow-up was 15.2 months. There were 83 VTEs (11.5%) and 568 (78.8%) patients died. A high KRS (cumulative incidence, 12.4%; 95% confidence interval [CI], 6.4-20.5%) was not associated with VTE compared with an intermediate score (cumulative incidence, 12.1%; 95% confidence interval, 9.5-15.0%) in both univariate and multivariable analyses. However, a high KRS was a predictor of mortality (hazard ratio, 1.7; 95% CI, 1.4-2.2). Conclusions Among patients with lung cancer, the KRS did not stratify the patients at the highest risk of VTE. Improved risk stratification methods are needed for this group of patients prior to implementing a primary prevention strategy.
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Affiliation(s)
- Aaron Mansfield
- Department of Oncology, Division of Medical Oncology, Mayo Clinic,
200 First Street SW, Rochester, MN 55905, U.S
| | - Alfonso J. Tafur
- Department of Medicine, Division of Cardiology - Vascular Medicine
Program, NorthShore University Health System, 2650 Ridge Avenue, Evanston IL, 60201;
University of Chicago School of Medicine, Chicago, IL, U.S.,
| | - Chihsiung E. Wang
- Department of Surgery, NorthShore University Health System, 2650
Ridge Avenue, Evanston IL, 60201,
| | - Taxiarchis V. Kourelis
- Department of Medicine, Division of Hematology; Department of
Oncology, Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester,
MN 55905, U.S.,
| | - Ewa M. Wysokinska
- Willmar Regional Cancer Center, 301 Becky Avenue SW, Willmar, MN
56201, U.S.,
| | - Ping Yang
- Department of Health Sciences Research, Division of Epidemiology,
Mayo Clinic, 200 First Street SW, Rochester, MN 55905, U.S.,
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Tafur AJ, Dale G, Cherry M, Wren JD, Mansfield AS, Comp P, Rathbun S, Stoner JA. Prospective evaluation of protein C and factor VIII in prediction of cancer-associated thrombosis. Thromb Res 2015; 136:1120-5. [PMID: 26475410 PMCID: PMC4679511 DOI: 10.1016/j.thromres.2015.10.004] [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] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/02/2015] [Accepted: 10/04/2015] [Indexed: 12/12/2022]
Abstract
Venous thromboembolism (VTE) is a preventable disease, yet it is one of the leading causes of death among patients with cancer. Improving risk stratification mechanisms will allow us to personalize thrombo-prophylaxis strategies. We sought to evaluate Collagen and Thrombin Activated Platelets (COAT-platelets) as well as protein C and factor VIII as biomarkers predictive of cancer-associated thrombosis in a prospective cohort of patients with cancer. Protein C was selected as a candidate based on bioinformatics prediction. Blood samples were collected before chemotherapy. All specimen processing was blinded to clinical data. Surveillance and adjudication of the main outcome of VTE was performed for up to 1 year. We used Cox proportional hazard regression to measure the association of biomarkers and incident events using SAS 9.2 for all statistical analysis. Death was modeled as a competing event. Among 241 patients followed for an average of 10.4 months, 15% died and 13% developed a VTE. COAT-platelets were not predictive of VTE. Low levels of pre-chemotherapy protein C (<118%) (HR 2.5; 95% CI 1.1-5.5) and high baseline factor VIII (>261% I) (HR 3.0; 95% CI 1.1-8.0) were predictive of VTE after adjusting for age, Khorana prediction risk, metastatic disease and D dimer. In addition, low protein C was predictive of overall mortality independent of age, metastatic disease and functional status (HR 2.8; 95% CI 1.3-6.0). Addition of these biomarkers to cancer-VTE risk prediction models may add to risk stratification and patient selection to optimize thrombo-prophylaxis.
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Affiliation(s)
- A J Tafur
- Department of Medicine - Cardiology-Vascular Section, University of Oklahoma Health Sciences Center, United States.
| | - G Dale
- Department of Medicine - Cardiology-Vascular Section, University of Oklahoma Health Sciences Center, United States
| | - M Cherry
- Department of Medicine - Hematology-Oncology section, University of Oklahoma Health Sciences Center, United States
| | - J D Wren
- Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, United States
| | - A S Mansfield
- Department of Oncology, Division of Medical Oncology, Mayo Clinic Rochester, United States
| | - P Comp
- Department of Medicine - Hematology-Oncology section, University of Oklahoma Health Sciences Center, United States
| | - S Rathbun
- Department of Medicine - Cardiology-Vascular Section, University of Oklahoma Health Sciences Center, United States
| | - J A Stoner
- Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, United States
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Casanegra A, Mansfield A, Tafur A. Primary venous thromboembolism prophylaxis in patients with solid tumors. J Thromb Thrombolysis 2014; 39:258-9. [PMID: 25486907 DOI: 10.1007/s11239-014-1152-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- A Casanegra
- Cardiovascular Medicine Section, Health Sciences Center, University of Oklahoma, 920 Stanton L Young Blvd., WP3010, Oklahoma, OK, 73104, USA
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Akl EA, Kahale LA, Ballout RA, Barba M, Yosuico VED, van Doormaal FF, Middeldorp S, Bryant A, Schünemann H. Parenteral anticoagulation in ambulatory patients with cancer. Cochrane Database Syst Rev 2014:CD006652. [PMID: 25491949 DOI: 10.1002/14651858.cd006652.pub4] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Anticoagulation may improve survival in patients with cancer through an antitumor effect in addition to the perceived antithrombotic effect. OBJECTIVES To evaluate the efficacy and safety of parenteral anticoagulants in ambulatory patients with cancer who, typically, are undergoing chemotherapy, hormonal therapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation. SEARCH METHODS A comprehensive search included (1) an electronic search (February 2013) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to February 2013; accessed via OVID) and EMBASE(1980 to February 2013; accessed via OVID); (2) handsearching of conference proceedings; (3) checking of references of included studies; (4) use of the 'related citation' feature in PubMed and (5) a search for ongoing studies. SELECTION CRITERIA Randomized controlled trials (RCTs) assessing the benefits and harms of parenteral anticoagulation in ambulatory patients with cancer. Typically, these patients are undergoing chemotherapy, hormonal therapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation. DATA COLLECTION AND ANALYSIS Using a standardized form we extracted data in duplicate on methodological quality, participants, interventions and outcomes of interest including all-cause mortality, symptomatic venous thromboembolism (VTE), symptomatic deep vein thrombosis (DVT), symptomatic pulmonary embolism (PE), arterial thrombosis (e.g. stroke, myocardial infarction), major bleeding, minor bleeding and quality of life. MAIN RESULTS Of 9559 identified citations, 15 RCTs fulfilled the eligibility criteria. These trials enrolled 7622 participants for whom follow-up data were available. In all included RCTs the intervention consisted of heparin (either unfractionated heparin or low molecular weight heparin). Overall, heparin may have a small effect on mortality at 12 months and 24 months (risk ratio (RR) 0.97; 95% confidence interval (CI) 0.92 to 1.01 and RR 0.95; 95% CI 0.90 to 1.00, respectively). Heparin therapy was associated with a statistically and clinically important reduction in venous thromboembolism (RR 0.56; 95% CI 0.42 to 0.74) and a clinically important increase in the risk of minor bleeding (RR 1.32; 95% 1.02 to 1.71). Results failed to show or to exclude a beneficial or detrimental effect of heparin on major bleeding (RR 1.14; 95% CI 0.70 to 1.85) or quality of life. Our confidence in the effect estimates (i.e. quality of evidence) was high for symptomatic venous thromboembolism, moderate for mortality, major bleeding and minor bleeding, and low for quality of life. AUTHORS' CONCLUSIONS Heparin may have a small effect on mortality at 12 months and 24 months. It is associated with a reduction in venous thromboembolism and a likely increase in minor bleeding. Future research should further investigate the survival benefit of different types of anticoagulants in patients with different types and stages of cancer. The decision for a patient with cancer to start heparin therapy for survival benefit should balance the benefits and downsides, and should integrate the patient's values and preferences.
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Affiliation(s)
- Elie A Akl
- Department of Internal Medicine, American University of Beirut, Riad El Solh St, Beirut, Lebanon.
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Kourelis TV, Wysokinska EM, Wang Y, Yang P, Mansfield AS, Tafur AJ. Early venous thromboembolic events are associated with worse prognosis in patients with lung cancer. Lung Cancer 2014; 86:358-62. [PMID: 25453848 DOI: 10.1016/j.lungcan.2014.10.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/30/2014] [Accepted: 10/04/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Venous thromboembolic events (VTE) are a leading cause of death in cancer patients. We hypothesized that early VTE (EVTE, within 3 months of diagnosis) in patients with lung cancer (LC) are associated with worse overall survival (OS). MATERIALS AND METHODS We identified 727 patients with LC between 1998 and 2011. Late VTE (LVTE) were defined as VTE occurring after 3 months from LC diagnosis. Advance disease (AD) was defined as patients with Stage IV non-small cell lung cancer (NSCLC) or extensive stage small cell lung cancer (SCLC), and non-advanced disease (non-AD) was defined as ≤ Stage III NSCLC or limited stage SCLC. RESULTS Out of 727 patients included in our review, 617 patients had NSCLC (85%), 94 (13%) SCLC, and 16 (2%) low grade neuroendocrine tumors. Ninety five patients (13%) experienced VTE, 44 (6%) experienced an EVTE and 49 (7%) had a LVTE. Patients with an EVTE had worse OS when compared to all other patients (medians 4 vs. 17 months, p < 0.0001). EVTE were associated with worse OS in patients with non-AD (medians 12 vs. 42 months, p = 0.01) and AD (medians 4 vs. 6 months, p = 0.02). When considering patients with NSCLC only, in a multivariate model that included age, stage, performance status >2, administration of chemotherapy and Charlson comorbidity index, EVTE were an independent predictor of increased mortality (HR 2.4; 95% CI 1.6-3.3). CONCLUSIONS EVTE are associated with worse OS, irrespective of stage of the disease. Our findings underscore the need for an efficient preventive strategy for VTE among patients with lung cancer.
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Affiliation(s)
| | | | - Yi Wang
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic, Rochester, MN, USA; Division of Preventive Medicine, School of Environmental Science and Public Health, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ping Yang
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | | | - Alfonso J Tafur
- Section of Cardiology - Vascular Medicine, Oklahoma University Health Sciences Center, USA.
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Tun NM. Primary thromboprophylaxis in patients with solid cancers. J Thromb Thrombolysis 2014; 39:260-1. [PMID: 25231275 DOI: 10.1007/s11239-014-1138-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Nay Min Tun
- Division of Hematology and Oncology, The Brooklyn Hospital Center, 121 Dekalb Ave, Brooklyn, NY, 11201, USA,
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Bemiparin, an effective and safe low molecular weight heparin: A review. Vascul Pharmacol 2014; 62:32-7. [PMID: 24657810 DOI: 10.1016/j.vph.2014.03.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 02/13/2014] [Accepted: 03/11/2014] [Indexed: 02/07/2023]
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