Venous Thromboembolism in Surgical Lung Cancer Patients: A Provincial Population-Based Study

In-hospital thromboprophylaxis variation and the risk of venous thromboembolism after lung cancer surgery: a nationwide cohort study

OBJECTIVES

Venous thromboembolic event (VTE) is a severe complication in patients with lung cancer undergoing thoracic surgery. Nevertheless, because of insufficient evidence, there are no clear guidelines, and VTE prophylaxis practices vary widely. This nationwide cohort study was a comparative study investigating VTE risk in surgical departments that routinely administered in-hospital thromboprophylaxis with low-molecular-weight heparin compared to those that did not.

METHODS

We identified all patients with non-small-cell lung cancer (NSCLC) who underwent surgery in Denmark during 2010-2021. Thoracic surgery was exclusively performed in the 4 university hospitals. Three hospitals implemented in-hospital thromboprophylaxis as standard care since 2000, while the fourth adopted this practice in September 2016. VTE events were assessed at 6-month follow-up according to hospital and study period, using an inverse probability of treatment weighting approach.

RESULTS

We identified 9615 patients. During 6-month follow-up, a total of 190 VTE events were observed, resulting in a weighted rate of 4.5 events per 100 person-years and an absolute risk of 2.2%. There was no clear trend according to hospital site or use of in-hospital thromboprophylaxis with a 2.2% risk in the hospital not using thromboprophylaxis compared to 1.7-3.1% in those that did.

CONCLUSIONS

Use of in-hospital thromboprophylaxis did not affect the risk of VTE after surgery for NSCLC, suggesting that relying solely on in-hospital thromboprophylaxis may be insufficient to mitigate VTE risk in these patients. Further research is warranted to investigate the potential benefits of extended thromboprophylaxis in reducing VTE risk in selected NSCLC surgical patients.

Enhanced Recovery after Surgery (ERAS) in Postoperative Lung Cancer Patients: A Novel Perioperative Strategy for Preventing Venous Thromboembolism and Improving Quality of Life

This study aimed to assess the impact of enhanced recovery after surgery (ERAS) intervention in preventing venous thromboembolism (VTE) among postoperative lung cancer patients. Conducted from January 2022 to January 2023, the research involved 125 lung cancer patients randomly assigned to either a control group (n = 60) receiving routine care, or an ERAS group (n = 65) which received both routine care and ERAS interventions. The ERAS program comprised a comprehensive series of interventions meticulously implemented throughout the preoperative, intraoperative, and postoperative phases. Thrombotic risk assessment using the Caprini Risk Assessment Model (RAM) was conducted preoperatively and on postoperative day 5 (POD 5), with plasma D-dimer levels measured preoperatively, on POD 1, POD 3, and POD 5. Quality of life and patient satisfaction were assessed at discharge using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Lung Cancer Module 13 (QLQ-LC13) and The Newcastle Satisfaction with Nursing Scale (NSNS), respectively. The ERAS group demonstrated significantly lower Caprini RAM scores on POD 5 compared to the control group, with lower D-dimer levels on POD 3 and POD 5. The incidence of VTE was lower in the ERAS group (1.54%) compared to the control group (11.67%) during hospitalization. At discharge, the ERAS group showed improved quality of life, with higher satisfaction scores for nursing care and their hospital stay. ERAS nursing interventions effectively mitigate thrombotic risk, improve D-dimer levels, enhance postoperative quality of life, and elevate patient satisfaction among individuals undergoing lung cancer surgery.

Risk and Timing of Venous Thromboembolism After Surgery for Lung Cancer: A Nationwide Cohort Study

BACKGROUND

Venous thromboembolism (VTE) is a potentially preventable serious complication in patients with lung cancer undergoing thoracic operation. We examined the risk and timing of VTE after surgery for primary non-small cell lung cancer (NSCLC).

METHODS

All patients undergoing operation for NSCLC in Denmark between 2003 and 2021 were identified in the Danish Lung Cancer Registry. VTE events in the year after operation were assessed by stage, patient characteristics, and surgical procedure.

RESULTS

We identified 13,197 patients who underwent operation for NSCLC in 2003 to 2021 (mean age, 67.6 years; 50% female); 10,524 (79.7%) had stage I-II NSCLC, and 2673 (20.3%) had stage III-IV. During 1-year follow-up, there were 335 VTE events, yielding a rate of 2.87 events/100 person-years and an absolute risk of 3.3% (95% CI, 2.3-4.0). VTE risk increased with advancing cancer stage (1.8% for stage I vs 3.9% for stage IV) but varied little by pathologic type, sex, and comorbidity level. Bilobectomy was associated with highest VTE risk (4.8%; 95% CI, 3.2-6.9), followed by pneumonectomy (3.5%; 95% CI, 2.3-5.0). The hazard of VTE was highest during the first 3 months after operation, after which it declined. For stage IV cancer, hazards increased again after 6 months. At 1 year, all-cause death was 12.6% (95% CI, 12.0%-13.1%).

CONCLUSIONS

VTE developed in 3.3% of patients undergoing operation for NSCLC, most commonly within 3 months postoperatively. Prolonged thromboprophylaxis could be considered, particularly in those with advanced cancer stage and undergoing extended resections.

Lung Cancer Related Thrombosis (LCART): Focus on Immune Checkpoint Blockade

Cancer-associated thrombosis (CAT) is a common complication in lung cancer patients. Lung cancer confers an increased risk of thrombosis compared to other solid malignancies across all stages of the disease. Newer treatment agents, including checkpoint immunotherapy and targeted agents, may further increase the risk of CAT. Different risk-assessment models, such as the Khorana Risk Score, and newer approaches that incorporate genetic risk factors have been used in lung cancer patients to evaluate the risk of thrombosis. The management of CAT is based on the results of large prospective trials, which show similar benefits to low-molecular-weight heparins (LMWHs) and direct oral anticoagulants (DOACs) in ambulatory patients. The anticoagulation agent and duration of therapy should be personalized according to lung cancer stage and histology, the presence of driver mutations and use of antineoplastic therapy, including recent curative lung surgery, chemotherapy or immunotherapy. Treatment options should be evaluated in the context of the COVID-19 pandemic, which has been shown to impact the thrombotic risk in cancer patients. This review focuses on the epidemiology, pathophysiology, risk factors, novel predictive scores and management of CAT in patients with active lung cancer, with a focus on immune checkpoint inhibitors.