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Bertoletti L, Lafaie L, LeConte T, Desage AL, Petit B, Ozturk L, Accassat S, Corbaux P, Poenou G. Do all patients with cancer thrombosis have the same risk of bleeding and recurrence? Particularities of lung cancer. Expert Rev Respir Med 2024; 18:5-7. [PMID: 38488035 DOI: 10.1080/17476348.2024.2331750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 03/13/2024] [Indexed: 03/19/2024]
Affiliation(s)
- Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, F-42055, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
| | - Ludovic Lafaie
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
- Service de Gérontologie Clinique, CHU de St Etienne, Saint-Etienne, France
| | - Thibault LeConte
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
| | - Anne-Laure Desage
- Service de Pneumologie et Oncologie Thoracique, CHU de St-Etienne, Saint-Etienne, France
| | - Bastien Petit
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
| | - Lutfi Ozturk
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
| | - Sandrine Accassat
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
| | - Pauline Corbaux
- Medical Oncology, Institut de Cancérologie et d'Hématologie Universitaire de Saint-Étienne (ICHUSE), Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Géraldine Poenou
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
- EA UCBL/HCL 3738, Centre pour l'lnnovation en Cancérologie de Lyon (CICLY), Faculty of Medicine Lyon-Sud, Claude Bernard University Lyon 1, Lyon, France
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Napolitano M, Siragusa S. The Role of Injectables in the Treatment and Prevention of Cancer-Associated Thrombosis. Cancers (Basel) 2023; 15:4640. [PMID: 37760609 PMCID: PMC10526875 DOI: 10.3390/cancers15184640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Cancer-associated thrombosis (CAT) is a leading cause of death among patients with cancer. CAT can manifest itself as venous thromboembolism (VTE), in the form of deep vein thrombosis or pulmonary embolism, or arterial thromboembolism. The pathophysiology of CAT is complex and depends on cancer-, patient-, treatment- and biomarkers-related factors. Treatment of VTE in patients with cancer is complex and includes three major classes of anticoagulant agents: heparin and its derivatives, e.g., low molecular weight heparins, direct oral anticoagulants (DOACs), and vitamin K inhibitors. Given the tremendous heterogeneity of clinical situations in patients with cancer and the challenges of CAT, there is no single universal treatment option for patients suffering from or at risk of CAT. Initial studies suggested that patients seemed to prefer an anticoagulant that would not interfere with their cancer treatment, suggesting the primacy of cancer over VTE, and favoring efficacy and safety over convenience of route of administration. Recent studies show that when the efficacy and safety aspects are similar, patients prefer the oral route of administration. Despite this, injectables are a valid option for many patients with cancer.
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Affiliation(s)
- Mariasanta Napolitano
- Haematology Unit, Thrombosis and Haemostasis Reference Regional Center, University of Palermo, 90121 Palermo, Italy;
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Fioretti AM, Leopizzi T, Puzzovivo A, Giotta F, Lorusso V, Luzzi G, Oliva S. Cancer-Associated Thrombosis: Not All Low-Molecular-Weight Heparins Are the Same, Focus on Tinzaparin, A Narrative Review. Int J Clin Pract 2022; 2022:2582923. [PMID: 35936060 PMCID: PMC9325617 DOI: 10.1155/2022/2582923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 12/21/2022] Open
Abstract
Cancer-associated thrombosis (CAT) is the second main cause of cancer death with high related mortality and morbidity, leading to anticancer agent delays and interruptions. The recommended therapy, low-molecular-weight heparin (LMWH), however, is burdensome for patients and costly for society, as treatment should last until cancer is no longer active, even indefinitely. Tinzaparin is a manageable, efficient, safe, and cost-effective option. Compared to the other LMWHs, advantages are single-daily dose and safety in the elderly and those with renal impairment (RI). The purpose of this review is to critically discuss recent data on its efficacy and safety in CAT.
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Affiliation(s)
- Agnese Maria Fioretti
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Tiziana Leopizzi
- Cardiology-Intensive Care Unit, Ospedale SS. Annunziata, Via Francesco Bruno 1, 74121 Taranto, Italy
| | - Agata Puzzovivo
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Francesco Giotta
- Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Vito Lorusso
- Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Giovanni Luzzi
- Cardiology-Intensive Care Unit, Ospedale SS. Annunziata, Via Francesco Bruno 1, 74121 Taranto, Italy
| | - Stefano Oliva
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
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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: 384] [Impact Index Per Article: 128.0] [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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5
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Kirkilesis GI, Kakkos SK, Tsolakis IA. Editor's Choice – A Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients with Cancer. Eur J Vasc Endovasc Surg 2019; 57:685-701. [DOI: 10.1016/j.ejvs.2018.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/08/2018] [Indexed: 12/13/2022]
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Bellesoeur A, Thomas-Schoemann A, Allard M, Smadja D, Vidal M, Alexandre J, Goldwasser F, Blanchet B. Pharmacokinetic variability of anticoagulants in patients with cancer-associated thrombosis: Clinical consequences. Crit Rev Oncol Hematol 2018; 129:102-112. [DOI: 10.1016/j.critrevonc.2018.06.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 05/03/2018] [Accepted: 06/18/2018] [Indexed: 01/12/2023] Open
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Mahé I, Benhamou Y, Helfer H, Chidiac J. [Cancer and venous thromboembolism recurrence: The keys for an optimal management]. Bull Cancer 2018; 105:508-516. [PMID: 29544692 DOI: 10.1016/j.bulcan.2017.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 11/08/2017] [Accepted: 12/12/2017] [Indexed: 11/30/2022]
Abstract
Low-molecular-weight heparins (LMWH) are to date the standard for 3-to-6-month treatment of cancer-associated thrombosis (CAT) as they are consistently recommended by international clinical practice guidelines. Despite the high risk of VTE recurrence and death in patients with cancer and the favorable benefit-risk profile of LMWH demonstrated in randomized-control studies, the implementation of treatment guidelines remains insufficient in the clinical practice. A systematic review of observational studies, registries and surveys reveals that approximately only 50% of patients with CAT are treated according to practice guidelines while both physicians and patients may be accountable for this situation. Based on the few available published data, we have observed differences between guidelines and clinical practice and we have identified factors influencing patient's management with the perspective to improve adherence to clinical practice guidelines in patients with CAT. Improving the implementation of clinical practice guidelines requires a better knowledge of physician and patient-related factors that influence therapeutic decisions. A global approach of patients with CAT is warranted to optimize the therapeutic management of cancer-associated VTE.
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Affiliation(s)
- Isabelle Mahé
- AP-HP, université Paris 7, hôpital Louis-Mourier, service de médecine interne, 178, rue des Renouillers, 92700 Colombes, France; EA Remes 7334, université Paris Diderot, Sorbonne, hôpital Saint-Louis, 1, rue Claude-Vellefaux, 75010 Paris, France.
| | - Ygal Benhamou
- Hôpital Charles-Nicolle, service de médecine interne, 1, rue de Germont, 76000 Rouen, France
| | - Hélène Helfer
- AP-HP, université Paris 7, hôpital Louis-Mourier, service de médecine interne, 178, rue des Renouillers, 92700 Colombes, France
| | - Jean Chidiac
- AP-HP, université Paris 7, hôpital Louis-Mourier, service de médecine interne, 178, rue des Renouillers, 92700 Colombes, France
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Abstract
Current guidelines recommend low-molecular-weight heparin treatment in patients with cancer with established venous thromboembolism (VTE). The aim of this article was to study the pharmacological properties and effectiveness of tinzaparin in patients with cancer as well as its potential anticancer properties. A search of PubMed and ScienceDirect databases up to March 2016 was carried out to identify published studies that detect the properties and use of tinzaparin in oncology. Protamine sulfate partially (60% to 65%) neutralized tinzaparin’s anti-Xa activity. No dose adjustment of tinzaparin is needed even in patients with severe renal impairment and Creatinine Clearance ≥20 mL/min. Tinzaparin demonstrated a statistically significant decline in VTE recurrence at 1 year post the index thromboembolic event. A statistically significant reduction in minor bleeding rates was also described, whereas major bleeding events did not decrease in patients with cancer treated with tinzaparin versus those who received vitamin K antagonists. Tinzaparin treatment in patients suffering from deep vein thrombosis reduced the incidence of postthrombotic syndrome and venous ulcers. Tinzaparin’s ability to prevent both metastatic dissemination of cancer cells and tumor angiogenesis has been delineated in preclinical research. Current data show that tinzaparin is safe and efficacious either for short-term or for long-term treatment of VTE in patients with cancer. Clinical trials are needed in order to examine the utility of tinzaparin in primary prevention of VTE and validate its potential anticancer advantages exhibited in preclinical research.
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Affiliation(s)
- Evangelos P Dimakakos
- 1 Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Ioannis Vathiotis
- 1 Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Konstantinos Syrigos
- 1 Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
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9
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Elalamy I, Mahé I, Ageno W, Meyer G. Long-term treatment of cancer-associated thrombosis: the choice of the optimal anticoagulant. J Thromb Haemost 2017; 15:848-857. [PMID: 28222250 DOI: 10.1111/jth.13659] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Indexed: 01/20/2023]
Abstract
Patients with cancer-associated thrombosis (CAT) carry a higher risk of recurrence, bleeding and mortality as compared with non-cancer patients. The specific profiles of cancer patients, combining frequent co-morbidities, the use of anti-tumoral therapies and the cancer progression itself, represent a major therapeutic challenge for choosing a long-term anticoagulant treatment. This review discusses the practical basis of making a choice between the available drugs for a long-term antithrombotic strategy, linked to their pharmacology, mechanism of action, evidence of clinical benefits, and advantages and limitations in such a complex clinical context. In patients with cancer, low-molecular-weight heparins (LMWHs) are the preferred option for the secondary prevention of venous thromboembolism according to current guidelines, because their efficacy is significantly superior to vitamin K antagonists (VKAs). Even though LMWHs are effective and safe in cancer patients, they require daily subcutaneous injections, which may be problematic for a long-term therapy that may exceed 6 months' duration. Compared with VKAs, non-vitamin-K antagonist oral anticoagulants or direct oral anticoagulants (DOACs) are more target specific and do not require laboratory monitoring, whereas the oral route of administration makes them potentially attractive alternatives to LMWH. In randomized controlled trials in the general population DOACs have been shown to be non-inferior to VKAs in terms of efficacy with a lower rate of clinically relevant or major bleeding. However, given the limited number of cancer patients enrolled in these studies (with poorly defined active cancer), available trials are inconclusive regarding the usefulness of DOACs in the cancer setting. Ongoing head-to-head comparisons vs. LMWH in patients with CAT may allow an informed choice to be made regarding the DOAC option.
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Affiliation(s)
- I Elalamy
- Biological Hematology Department, Hôpital TENON APHP Hôpitaux Universitaires de l'Est Parisien, INSERM UMRS 938 Université Pierre et Marie Curie, Paris 6, Paris, France
| | - I Mahé
- Internal Medicine Department, Hôpital Louis Mourier, APHP, Colombes, France
- Université Paris-Diderot Paris 7, EA 7334, Sorbonne Paris Cité, Paris, France
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - G Meyer
- Respiratory and Intensive Care, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Université Paris Descartes Paris 5, Sorbonne Paris Cité, Paris, France
- INSERM UMRS 970, CIC 1418, Paris, France
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10
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Martínez-Zapata MJ, Mathioudakis AG, Mousa SA, Bauersachs R. Tinzaparin for Long-Term Treatment of Venous Thromboembolism in Patients With Cancer: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2017; 24:226-234. [PMID: 28288527 PMCID: PMC6714676 DOI: 10.1177/1076029617696581] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Patients with cancer are at increased risk of recurrent venous thromboembolism (VTE) and bleeding. Thus, long-term treatment with anticoagulants for secondary prevention is challenging. The objective of this review was to evaluate current evidence on the safety and efficacy of tinzaparin compared with other anticoagulants for long-term VTE treatment in patients with cancer. Based on a preregistered protocol, we identified randomized controlled trials (RCTs) comparing long-term tinzaparin (therapeutic dose: 175 IU/kg) versus other anticoagulants for at least 3 months after an acute episode of VTE that included adult patients with underlying malignancy. We extracted predefined, clinically relevant outcomes of patients with cancer and, using standard methodology, pooled available data and assessed risk of bias and quality of evidence for each study. Three open-label RCTs evaluating 1169 patients with cancer were included in the analysis. Tinzaparin was associated with a significantly lower risk of recurrent VTE at the end of treatment (relative risk [RR], [95% confidence interval] 0.67 [0.46-0.99]) and at longest follow-up (RR: 0.58 [0.39-0.88]) and showed a lower risk of clinically relevant non-major bleeding at the end of treatment (RR: 0.71 [0.51-1.00]). No significant between-treatment differences were found for all-cause mortality (RR: 1.09 [0.91-1.30]) or fatal and non-fatal major bleeding events (RR: 1.06 [0.56-1.99]). The overall quality of evidence was deemed moderate, mainly due to small sample size in 2 of the studies and limited number of events in the meta-analyses. In conclusion, both short- and long-term treatments with tinzaparin were found to be superior to vitamin K antagonists for avoiding recurrences of VTE.
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Affiliation(s)
- M José Martínez-Zapata
- 1 Public Health and Clinical Epidemiology Service, Instituto de Investigación Biomédica Sant Pau, CIBERESP, Barcelona, Spain
| | - Alexander G Mathioudakis
- 2 Division of Infection, Immunity and Respiratory Medicine, University Hospital of South Manchester NHS Foundation Trust, University of Manchester, Manchester, United Kingdom
| | - Shaker A Mousa
- 3 The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA
| | - Rupert Bauersachs
- 4 Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany.,5 Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany
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Mahé I, Chidiac J, Helfer H, Noble S. Factors influencing adherence to clinical guidelines in the management of cancer-associated thrombosis. J Thromb Haemost 2016; 14:2107-2113. [PMID: 27566698 DOI: 10.1111/jth.13483] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 08/22/2016] [Indexed: 11/27/2022]
Abstract
International academic and regulatory guidelines consistently recommend the long-term use of low-molecular-weight heparins (LMWHs) as the standard for the treatment of cancer-associated thrombosis (CAT). However, both physicians and patients are reluctant to follow established guidelines. Insufficient compliance with treatment recommendations among care physicians represents a loss of opportunity for patients at very high risk of recurrence of venous thromboembolism (VTE) and death. Few data are available regarding adherence to CAT clinical practice guidelines. Based on published data, we aimed to review the gap between guidelines and practice to draw a more precise picture of current practice in order to precisely identify the extent to which patient management is currently lacking with respect to treatment guidelines. Published observational studies, registries and surveys on cancer-associated VTE treatment were reviewed. In spite of evidence from randomized controlled trials (RCTs) showing the usefulness of long-term LMWH, only approximately 50% of patients are managed according to established guideline recommendations. Patient profiles and co-morbidities influence compliance with standard guidelines. A better knowledge of physician and patient-related factors that influence therapeutic decisions may improve the implementation of clinical practice guidelines. Efficient awareness programs including a multidisciplinary approach are necessary to implement guidelines aimed at optimizing the therapeutic management of cancer-associated VTE.
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Affiliation(s)
- I Mahé
- Department of Internal Medicine, Hôpital Louis Mourier, Colombes (APHP), University Paris 7, Colombes, France
- EA Remes 7334, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - J Chidiac
- Department of Internal Medicine, Hôpital Louis Mourier, Colombes (APHP), University Paris 7, Colombes, France
| | - H Helfer
- Department of Internal Medicine, Hôpital Louis Mourier, Colombes (APHP), University Paris 7, Colombes, France
| | - S Noble
- Cardiff University, Cardiff, Wales, UK
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12
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Cajfinger F, Debourdeau P, Lamblin A, Benatar V, Falvo N, Benhamou Y, Sevestre MA, Farge-Bancel D. Low-molecular-weight heparins for cancer-associated thrombosis: Adherence to clinical practice guidelines and patient perception in TROPIQUE, a 409-patient prospective observational study. Thromb Res 2016; 144:85-92. [PMID: 27318244 DOI: 10.1016/j.thromres.2016.06.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/18/2016] [Accepted: 06/07/2016] [Indexed: 02/01/2023]
Abstract
PURPOSE Data on long-term treatment with low-molecular-weight heparins (LMWH) in cancer patients treated for venous thromboembolism are scarce. Study objectives were to document the long-term clinical use of LMWH and patient perception in this setting. METHODS Adult cancer patients receiving antineoplastic treatment or palliative care and LMWH for cancer associated venous thromboembolism (CAT) were eligible to participate in this prospective observational study. Main outcome was adherence to clinical practice guidelines based on recommended LMWH treatment doses for at least 3months in the absence of severe renal insufficiency. Patients' perception of the treatment was assessed in an ancillary study using the Perception Anticoagulant Treatment Questionnaire (PACT-Q). RESULTS Among 409 included cancer patients aged 65±12.1years, overall adherence to practice guidelines as defined in the protocol was 55.3% (226 patients). However, 98.0% of patients received a prescription for 3months or more and mean LMWH treatment duration for VTE was 6.27±0.15months which meets guidelines recommendations. Main patients' expectations scored on a 1-5 scale were blood clots prevention (mean 3.94±0.75), symptom relief (mean 3.98±1.04) and ease of use (mean 4.22±0.9). LMWH treatment appeared convenient (global score 79.7±17.1 on a 0 to 100 scale) and 69.1% of patients were satisfied or very satisfied. CONCLUSION Despite incomplete strict adherence to guidelines, treatment duration with LMWH was adequate showing substantial progress in the management of CAT patients. Patients expectations were high while treatment was perceived convenient with a high degree of satisfaction.
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Affiliation(s)
- F Cajfinger
- Oncologie Médicale, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France
| | - P Debourdeau
- Oncologie, Institut Sainte Catherine, 250 Chemin de Baigne-pieds CS 800005, 84918 Avignon Cedex 9, , France
| | - A Lamblin
- LEO Pharma France, 2 rue René Caudron, F-78960, Voisins-le-Bretonneux, France
| | - V Benatar
- HEATHICS Clinical Consultants, 111, rue des Tennerolles, 92210 Saint-Cloud, France.
| | - N Falvo
- Département de Pathologie Vasculaire, CHU Dijon, 14 rue Gaffarel, 21079 Dijon cedex, France
| | - Y Benhamou
- Département de Médecine Interne, INSERM U1096, Centre Hospitalier Universitaire de Rouen, 1 rue de Germont, 76000 Rouen, France
| | - M A Sevestre
- Service de Médecine Vasculaire, CHU Amiens-Picardie- Site Sud, 80054 Amiens cedex, France
| | - D Farge-Bancel
- Unité de Médecine Interne et Pathologie Vasculaire, INSERM UMRS 1160, Hopital St Louis, 1 avenue Claude Vellefaux, 75010 Paris, France
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Appelmann I, Kreher S, Parmentier S, Wolf HH, Bisping G, Kirschner M, Bergmann F, Schilling K, Brümmendorf TH, Petrides PE, Tiede A, Matzdorff A, Griesshammer M, Riess H, Koschmieder S. Diagnosis, prevention, and management of bleeding episodes in Philadelphia-negative myeloproliferative neoplasms: recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society of Thrombosis and Hemostasis Research (GTH). Ann Hematol 2016; 95:707-18. [PMID: 26916570 DOI: 10.1007/s00277-016-2621-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/31/2022]
Abstract
Philadelphia-negative myeloproliferative neoplasms (Ph-negative MPN) comprise a heterogeneous group of chronic hematologic malignancies. The quality of life, morbidity, and mortality of patients with MPN are primarily affected by disease-related symptoms, thromboembolic and hemorrhagic complications, and progression to myelofibrosis and acute leukemia. Major bleeding represents a common and important complication in MPN, and the incidence of such bleeding events will become even more relevant in the future due to the increasing disease prevalence and survival of MPN patients. This review discusses the causes, differential diagnoses, prevention, and management of bleeding episodes in patients with MPN, aiming at defining updated standards of care in these often challenging situations.
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Affiliation(s)
- Iris Appelmann
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Stephan Kreher
- Department of Hematology and Oncology, Charite Berlin, Berlin, Germany
| | - Stefani Parmentier
- Department of Hematology, Oncology, and Palliative Medicine, Rems-Murr-Klinikum Winnenden, Winnenden, Germany
| | - Hans-Heinrich Wolf
- Department of Internal Medicine IV, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Guido Bisping
- Department of Medicine I, Mathias Spital Rheine, Rheine, Germany
| | - Martin Kirschner
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Frauke Bergmann
- Medizinisches Versorgungszentrum Wagnerstibbe, Hannover, Germany
| | - Kristina Schilling
- Department of Hematology and Oncology, University Hospital Jena, Jena, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Petro E Petrides
- Hematology Oncology Centre, Ludwig Maximilians University of Munich Medical School, Munich, Germany
| | - Andreas Tiede
- Department of Haematology, Haemostasis, Oncology and Stem-Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Axel Matzdorff
- Clinic for Internal Medicine II, Dept. of Hematology, Oncology, Asklepios Clinic Uckermark, Schwedt/Oder, Germany
| | | | - Hanno Riess
- Department of Hematology and Oncology, Charite Berlin, Berlin, Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany.
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Salla E, Dimakakos EP, Tsagkouli S, Giozos I, Charpidou A, Kainis E, Syrigos KN. Venous Thromboembolism in Patients Diagnosed With Lung Cancer. Angiology 2015; 67:709-24. [PMID: 26553057 DOI: 10.1177/0003319715614945] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Considering the high prevalence of lung cancer, our purpose was to summarize the existing literature to identify the several factors that contribute to the increased risk of venous thromboembolism (VTE) in patients with lung cancer and to analyze the current recommendations for thromboprophylaxis and treatment of VTE in those patients. METHODS We searched the Medline and EMBASE databases from February 1985 to February 2014 to identify retrospective and prospective randomized controlled studies that investigate one or more risk factors for VTEs in patients with lung cancer. RESULTS A VTE is a major complication for patients diagnosed with lung cancer. The risk factors for VTE events in patients with lung cancer consist of cancer-related (histological type and stage of cancer), treatment-related (surgery, chemotherapy, angiogenic agents, and supportive care agents), and patient-related factors (comorbidities, immobility, performance status, and prior thrombosis). Low-molecular-weight heparins are recommended for long-term treatment of cancer-associated thrombosis. Duration of anticoagulant therapy beyond 6 months should be based on individual clinical evaluation. Thromboprophylaxis for patients with lung cancer during hospitalization and immediate postoperative period is well established. CONCLUSIONS Efforts to assess thrombotic risk in patients with lung cancer may improve therapeutic and preventive strategies in the future, with final goal to minimize the burden and consequences of thrombotic events in patients with lung cancer.
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Affiliation(s)
- E Salla
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Evangelos P Dimakakos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - S Tsagkouli
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - I Giozos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - A Charpidou
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - E Kainis
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - K N Syrigos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece Yale School of Medicine, New Haven, CT, USA
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Zhang S, Zhai Z, Yang Y, Zhu J, Gong J, Xie W, Kuang T, Wang C. Long-term treatment with low-molecular-weight heparin prolonged the survival time for acute pulmonary embolism patients concurrent with malignancy: An observational analysis from a long-term follow-up study. Thromb Res 2015; 135:582-7. [DOI: 10.1016/j.thromres.2014.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 11/11/2014] [Accepted: 11/16/2014] [Indexed: 10/24/2022]
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[Cancer-associated venous thromboembolic recurrence: disregard of treatment recommendations]. Bull Cancer 2014; 101:295-301. [PMID: 24691192 DOI: 10.1684/bdc.2014.1907] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Low-molecular-weight heparins (LMWH) are the reference curative treatment of venous thromboembolism (VTE) in patients with cancer. All international guidelines recommend the long-term use of LMWH given their demonstrated superiority compared to vitamin-K antagonists (VKA) in reducing VTE recurrence in this patient population without increased risk of bleeding. However, several studies consistently show a lack of adherence to treatment recommendations, which are applied at the very best in 50% of cases. This results in a loss of chance for patients with fragile prognosis and in whom VTE represents the second cause of death. Given the expected benefit and the increased VTE prevalence in patients with cancer, full awareness is necessary to implement programs aiming at improving the therapeutic management of cancer-associated VTE. This requires multidisciplinary consideration by qualified physicians involved in the management of patients with cancer-associated VTE such as oncologists, internists and those specialized in vascular disease and hemostasis.
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Kreher S, Riess H. [Prophylaxis and treatment of venous thromboembolism in cancer patients. Clinical value of low-molecular-weight heparins]. Internist (Berl) 2014; 55:448-54. [PMID: 24599489 DOI: 10.1007/s00108-014-3476-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. Because of their improved subcutaneous bioavailability and reliable antithrombotic efficiency low-molecular-weight heparins (LMWH) are preferably used for prevention and treatment of cancer-related VTE. Thromboprophylaxis with LMWH is well established in patients undergoing cancer surgery and hospitalized cancer patients, while outpatient prophylaxis remains contentious. LMWH are recommended over unfractionated heparins and vitamin K antagonists for initial treatment and secondary prophylaxis (3-6 months) after cancer-related VTE. Long-term secondary prophylaxis should be considered for patients with ongoing active malignancy and low bleeding risk. Due to absence of clinical studies in cancer patients, the use of novel oral anticoagulants is currently not recommended.
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Affiliation(s)
- S Kreher
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland,
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Hull RD, Townshend G. Long-term treatment of deep-vein thrombosis with low-molecular-weight heparin: an update of the evidence. Thromb Haemost 2013; 110:14-22. [PMID: 23615656 DOI: 10.1160/th12-12-0931] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/21/2013] [Indexed: 11/05/2022]
Abstract
This article reviews updated evidence-based knowledge on long-term treatment of deep-vein thrombosis (DVT) with low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKAs). Eleven trials were identified comparing the two treatments in a broad spectrum of patients with DVT and with >100 study participants. Four comparative trials were identified in patients with cancer and DVT (in whom anticoagulation treatment is more complex and bleeding complications more frequent). In the 11 trials in broad patient populations, LMWHs were as effective as VKAs in preventing recurrent venous thromboembolism (VTE), and there were no consistent differences in the incidence of bleeding complications during long-term treatment. In patients with cancer, VTE recurrence was significantly reduced with LMWH versus VKA in two studies, while major bleeding complications did not differ between groups in any of the four trials. Current evidence-based European and American guidelines recommend LMWH over VKA for the long-term treatment of DVT in patients with cancer. LMWH and VKA are recommended over the new oral anticoagulant drugs, for which there are limited data on use in long-term treatment. Post-thrombotic syndrome (PTS), a common complication of DVT, causes considerable morbidity. Long-term use of tinzaparin reduced the risk of PTS compared with VKA in one trial, and a meta-analysis of nine studies in total demonstrated a consistently favourable effect of LMWHs versus VKA on PTS-related outcomes. Given the limited treatment options available for PTS, this suggests that LMWHs provide a useful therapeutic option in any patient particularly at risk of developing PTS.
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Affiliation(s)
- Russell D Hull
- University of Calgary, 2500 University Drive Northwest, Calgary, Alberta T2N 1N4, Canada.
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